206 - Exercising for longevity: strength, stability, zone 2, zone 5, and more | Peter Attia, M.D.

1. 0:00 – 3:00

   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] Welcome to a special episode of "The Drive." Now that we've released over 200 episodes, we realize we've covered a lot of stuff across various topics and in a lot of detail that I think, frankly, for people can be very difficult if you're not someone who started listening four years ago. I think even if you were listening from the very beginning, it can be really hard at times to kind of piece together all of the information. So we thought about trying an experiment for today's episode. We've decided to pull a variety of clips from previous podcasts, but around a given theme. And in this episode, we're gonna focus on clips that discuss exercise and my framework for it. So we put these clips in order of what we think is the best way to listen from top to bottom. So think of this as kind of a mashup of a whole bunch of things on exercise, but they're organized in a way that I think should make, frankly, a lot of sense and hopefully provide even more value than if you were to listen to each of these podcasts in their completeness. So the hope here, of course, is that this is gonna allow you to understand this topic better, but also to identify some previous episodes if you now wanna go back and dive really deep into those. First set of clips we're going to look at is what I'm optimizing for with my exercise and why I think training for the Centenarian Olympics or Centenarian Decathlon, as I more commonly refer to it these days, is so important. The last thing to note here is that some of these clips are actually from AMAs, and so if you're not a subscriber, hopefully this gives you a sense of what lives behind that paywall and why we think there's a lot of value there. Additionally, for the stability and DNS content clips, in our episode with Beth Lewis and Michael Rintala, we actually filmed a lot of instructional videos of them showing us how to do these exercises. I recommend you spend the time to go and look at those videos, because I think seeing here is probably better than just hearing. So this is the first time we're doing this, so would love your feedback. So tell us what you think about this, and tell us if this is the kind of thing you'd like to see more of. And tell us if you think it sucks, 'cause it's a lot of work to do this, and if you think it sucks, I'd be happy to not do this anymore. So without further delay, I hope you enjoy this special episode of "The Drive." [upbeat music]

2. 3:00 – 6:10

   What is Peter optimizing for with his exercise?

   1. PAPeter Attia3:01

      Everything we're talking about, Bob, right now is based on longevity, and that's very different than if you were asking this question through the lens of performance. Does that point kind of make sense, or should I expand on that a bit?

   2. SPSpeaker3:13

      Yeah, I think you should expand a little bit, maybe on the performance, health, and longevity, particularly performance and longevity and the possible trade-off between the two.

   3. PAPeter Attia3:21

      If someone said to me, "Peter, my goal is to break two hours and 40 minutes on the Chicago Marathon next year," I would be talking about this in a totally different manner. That is a very difficult performance goal, and that requires training at an energy system that I'm not even really gonna talk about in the context of longevity. If someone says, "I wanna break 10 hours on the Ironman," if someone says, "I wanna deadlift three and a half times my body weight," if you start to really look into the far recesses of amazing physical performance, everything I'm saying needs to be modified, and I'm not gonna talk about what those things look like. What I will say is they are generally not collinear with longevity, and at times they can be outright orthogonal. And I realize as that's coming out of my mouth, it sounds pretty fricking stupid if you're not a math person, so let me explain what that means in English. Something is collinear when it's directly in line with. Something is orthogonal when it is completely at odds with or at 90 degrees to. So trying to run the fastest 10K is training at an energy system that is very demanding of the cardiovascular system. It is pretty much maximum cardiac output just beneath VO2 max, above functional threshold. It puts an amazing strain on the body. And frankly, while doing that is better than sitting on a couch all day, that is generally past the point of optimizing longevity returns, and it actually comes at some longevity cost relative to something more at a slightly lower energy system. So everything I'm talking about is geared towards this Centenarian Olympics, which we've talked about in the past, this idea of being the most kickass 90-year-old possible. And that's really based on two energy systems. So it's got the stability and the strength piece we talked about, and then it's got this low-end aerobic energy system, which is zone 2 that we'll talk about in a second. And then I think it's punctuated with brief bursts of generally zone 5. And the reason I think those two matter is that's generally where life takes place. Life is zone 1, zone 2, and zone 5. And so by training zone 2 and zone 5, obviously much more in zone 2 than zone 5, we're really teeing ourselves up Metabolically and also structurally to do these things.

   4. SPSpeaker6:05

      [Instrumental music]

3. 6:10 – 21:48

   Preparing for a good life at age 100: Training for the “Centenarian Olympics”

   1. SPSpeaker6:11

      Based on what you know today, what do you wish you would have implemented when it comes to physical conditioning/training when you were at the age of 25? To make the question more general, what do you believe is typically overlooked in this realm among very active 25-year-olds who wish to be in the race for the gold medals in the Centenarian Olympics?

   2. PAPeter Attia6:32

      Hmm. Boy, that's a question from my heart. Have I spoken publicly about the Centenarian Decathlon and the Centenarian Olympics? I didn't realize I had, but obviously I have-

   3. SPSpeaker6:42

      I think you must have-

   4. PAPeter Attia6:42

      ... given the question

   5. SPSpeaker6:42

      ... because there's a, there's a number of questions that talk about the Centenarian Olympics, unless there's a Centenarian Olympics, I don't...

   6. PAPeter Attia6:48

      I honestly don't remember talking about this, so, but I did. Let me restate what I'm talking about, and that will put this question in context. About, I don't know, nine months ago, maybe a year ago, I just sort of had this epiphany, which was that the system's gonna fail first in body for most people, which isn't to say always, right? So some people just die suddenly, you know, their mind and their body are fine, but they get struck with a disease and they die. For another subset of people, unfortunately not that small, their mind is taken from them first, so cognition gets robbed of them, and then eventually, you know, either they die or their body also breaks down and away they go. But, but as I really reflected on what's going on, I think that for most people, the decline of mind, body, and then the burden of disease seems to be one by one in the wrong way, meaning body seems to fail first. So it got me thinking that, at least for me, how would I mitigate that? So I came up with this idea of backcasting instead of forecasting what I wanna do in the end, and I borrow that term backcasting from Annie Duke, who wrote Thinking in Bets, a book that I love, and Annie will also be a guest on the, uh, podcast soon, I hope. So the idea of backcasting is instead of trying to say, well, if I'm 25, what do I need to be doing tomorrow when I'm 26? And then what do I need to be doing when I'm 30? And what am I doing at 40? An easier way to do it is say, what do I need to be doing when I'm 100? And then how do I work backwards from that? And so for me, as a ripe old 46-year-old, 45-year-old when I started thinking about this, the, the question was, okay, well, if I wanna live to 100, and again, genetically speaking, I probably won't because I don't have the genes to, to get there, but let's assume that I can eke my way out to 100. That's 55 years away. What do I have to physically be able to do to be satisfied with my life? So as I went through that exercise, the way I did it was doing it through the lens of my kids. So I took the ages of my kids, and I projected them forward to how old will they be when I'm 100, and that's an easy calculation to do. Obviously, anybody can do that for themselves. And then I said, "Well, probabilistically, how old will their kids be?" So I said, "Well, you know, my kids are this, this, this. Their kids will be approximately this range." And then you realize, wow, their kids are gonna have kids by the time I'm 100. So by the time I'm 100, I'm going to have great-grandchildren that will likely be between, like, one and seven or eight. That's basically my calculation. Okay, so then I thought, okay, well, what are the things I'm gonna wanna be able to do when I'm 100 to just be happy? So it goes without saying I would love to not be, you know, bedridden with disease per se. It also goes without saying that I would love to have the, the cognitive faculties that I have, or at least a high enough amount of them that I'm able to sort of have the executive function, processing speed, and, you know, memory that's necessary to sort of function. But then I really kind of double-clicked on the physical part of this. So there are a bunch of activities that I wanna be able to do. I still wanna be able to shoot a bow and arrow. I still wanna be able to actually exercise, like, I do enjoy... You know, some people exercise because they have to. I think there are a number of us who exercise because we actually enjoy it and it, it's fortuitous that it provides benefit. But the one I really focused on was the real simple stuff, the activities of daily living, and among them is, like, playing with kids, right? So I started thinking about, well, what would I wanna be able to do with great-grandkids when I'm 100 and they're three, four, five? And in going through that, I made a list, and there were 18 things on my list, and I just began to refer to that as my Centenarian Decathlon, which is problematic because a decathlon has 10 things and my list has 18 things. But notwithstanding that tiny little detail, what's the Latin origin of 18? I assume deca is Latin for 10 of something, right? Anyway. Well, whatever. Okay. So we'll come up with a fancier term for it, or I'll figure out a way to consolidate. Nick, let us know. [laughs] So my Centenarian Decathlon has these 18 things that I wanna be able to do when I'm 100, and, uh, some of them seem so trivial that you'd be like, how is that even on your list? Like, for example, I wanna be able to get up off the floor with a single point of support, which means I wanna be able to, using just one arm, get up off the floor. Now, it's not that it's the end of the world if I need to use two arms, but, like, I wanna hold myself to that standard. I want to be able to drop into a squat position and pick up a child that weighs 30 pounds. I wanna be able to lift something that weighs 30 pounds over my head, 'cause that's about the weight of my little roller board suitcase, and I would really be bummed if I couldn't put that in the overhead compartment of an airplane. Presumably, I'll still be flying on airplanes and, you know, those will still exist.

   7. SPSpeaker11:34

      You'll be flying yourself probably.

   8. PAPeter Attia11:36

      [laughs] Yeah, yeah, right. We'll, we'll all have little jetpacks or something. You know, I wanna be able to get myself out of a pool without a ladder. Simple, right? Again, how trivial is that to do today where you have, you know, four inches between the concrete and the water, and how e- how easy is it for us to just pull ourselves out today without the ladder?

   9. SPSpeaker11:53

      You're seeing the guys that can jump without support, that can jump out of a pool, just jump out of a pool onto the platform.

   10. PAPeter Attia12:02

       No.

   11. SPSpeaker12:02

       Yeah. I think there's some videos-

   12. PAPeter Attia12:04

       Nice

   13. SPSpeaker12:04

       ... for that. Yeah.

   14. PAPeter Attia12:05

       So when I go through that whole thing, I then say Okay, what are physical tasks that would approximate those things? So for example, like picking up the 30-pound kid who comes running at you could be approximated by a 30-pound goblet squat. Lifting 30 pounds above your head in the form of a suitcase is also pretty easy to approximate with these things.

   15. SPSpeaker12:29

       Goblet squat, just, uh, for the uninitiated, I usually think of it as, uh, like a kettlebell, but almost like you're holding a goblet in front of you.

   16. PAPeter Attia12:36

       Mm-hmm.

   17. SPSpeaker12:36

       It's like a front squat-

   18. PAPeter Attia12:38

       That's right

   19. SPSpeaker12:38

       ... if you're going down, coming up.

   20. PAPeter Attia12:39

       That's right.

   21. SPSpeaker12:39

       Imagine picking a child up.

   22. PAPeter Attia12:40

       Yeah, so picking up a child. Then I've just been working backwards from there, which saying, well, if I want to be able to do these things at 100, there's going to be a decline. I have to be able to do these things at 80. I'm gonna need to be able to do it at this level at 60, and I need to be able to do it at this level today, again, given the inevitable decline. So most of my training today, in fact, I would argue all of my training today, centers around that. I no longer train for anything that's not related to that, so I don't do any training that's related to racing or competing in anything, which is not to say it's bad to do those things. I'm just saying that that's the point I'm at in my life. So this is kind of a long-winded answer to what I think is a great question, which is a 25-year-old who's frankly thinking of something that I-- most 25-year-olds, I can't imagine, would be thinking of. Certainly, I wasn't thinking of this at 25. I mean, at 25, [chuckles] you're sort of immortal. But whoever asked this question is presumably realizing that, hey, in 75 years, the world's gonna look different, and I want to be able to do X, Y, and Z. So I don't know the answer because I don't know what that person's limitations are today. So rather, I would just say, "What is the framework?" And my framework for thinking about this is four components of exercise. One is stability, the second is strength, the third is aerobic performance, the fourth is anaerobic output. And I didn't go through all of my 18, but each of my 18 touch at least one of those, and many touch more than one. For example, the goblet squat requires both strength and stability. Walking up... One of mine is being able to walk up three flights of stairs with 10 pounds of groceries in each hand. Again, you and I could do that today blindfolded and backwards. That starts to become harder when you get older. Well, that's got a little bit of aerobic. That's on the threshold of aerobic, anaerobic, and it's also got strength. So what I would be looking to do is say, "How well am I doing on each of those things?" Now, that said, in my experience, the one where most people start to fail first is stability because as a species, we usually begin to fail that once we enter school. And I think I've talked about this before, and I've certainly posted pictures of, like, my youngest son squatting.

   23. SPSpeaker14:57

       Yeah.

   24. PAPeter Attia14:57

       It's, it's just incredible. Like, the way that they can do this is so beautiful. You don't, you don't have to be a kinesiologist to look at them and go, "Wow, they're so natural when it comes to these movements," everything they do. And the field of dynamic neuromuscular stabilization is, in fact, built on this principle, which is, you know, there are about 13 or 14 movements that are completely innate to us, and by the time we're a year and a half old or so, we do them all perfectly, and then it's basically all downhill from there. Accelerated significantly by school. Once you start sitting, that's when we lose so much of that stability and we, you know, lose the ability to maintain tension through our pelvic floor and throughout the entire... I hate the term core, but core, of course, describing the diaphragm, the obliques, the transversalis fascia, and the entire pelvic floor. So my two cents would be spend as much time as possible working on dynamic stability, static stability. Static first, then dynamic. And as long as you incorporate those principles into what you are doing strength-wise, that's great, because at the age of 25, you can do a lot of dumb things and get away with it incorrectly. I think I've always squatted and deadlifted somewhat incorrectly. I don't think I've ever fully enga... In fact, I know I've never fully engaged my pelvic floor doing those, and I think I got away with murder for a long time, though I now realize the damage that's occurred as a result of it.

   25. SPSpeaker16:25

       Do you want to talk about your, I think it was your squat routine? I think you mentioned this to me one time way back when with your buddies.

   26. PAPeter Attia16:31

       Oh, my high school. Yeah.

   27. SPSpeaker16:32

       Yeah.

   28. PAPeter Attia16:33

       The breathing squats?

   29. SPSpeaker16:34

       Yeah.

   30. PAPeter Attia16:34

       Yeah. Amazing routine. I don't know that I recommend this, but again, if [chuckles] it was once a week. So we lifted six days a week in high school, three hours a day. I mean, we just lived in the gym. And on Fridays, we would do this routine of breathing squats, which was you took your best 10 rep weight, so a weight that you were gonna absolutely fail at 10 reps with, you load it on your back, and you do a rep and at the... So you go down and up at your normal cadence. At the top, you took three of the deepest breaths you could take, each breath taking 10 seconds. So that takes 30 seconds. So it's a [inhales] five in, [exhales] five out, three of those, and then do another rep, and you do 20 reps. So the set takes 10 minutes. And by the end, it's the only thing I've ever done since that rivals that degree of discomfort is, like, an air bike Tabata. And this was, like, one of these knucklehead things we got out of, like, our bodybuilding magazines for p- or powerlifting magazines, and the idea was, like, nothing will stimulate more strength and growth than that activity. And the reality of it is it worked.
4. 21:48 – 27:39

   The importance of preserving strength and muscle mass as we age

   1. PAPeter Attia21:49

      Now that we've set the stage for what we're optimizing for with our exercise, these next two clips are going to focus on strength, one of the pillars in my framework for exercise. The first clip is from a recent AMA on the importance of preserving strength and muscle mass as we age, and the second is from an older episode where I speak about the importance of deadlifts and why I think they're so beneficial to our longevity if we're able to do them safely. [upbeat music] Let's kind of just put some numbers to this. So what does it mean, you know, how much lean mass and strength are people losing by time? 'Cause I think this is another thing I try to communicate to patients a lot, which is, it goes back to that idea of what I said about the gravity of aging. You know, what is aging kind of robbing you of as time goes on? And you have got to fight like hell to avoid it. But basically, you look at multiple studies, they're gonna say min-- the lowest rate of decline that I could see is 1% per year. Another study, and we'll, we'll, we can post these studies in the show notes, you know, 1.3% per year. Others are sort of putting it 1 to 2% per year after 50, 35 to 40% between age 20 and 80. And the strength losses might even be greater, right? We're talking about 2 to 3, some studies even showing 4% strength loss per year. I mean, it's very difficult to put that in context, right? When you understand what compounding does. It gives you a sense of what it means to sort of be average when you're 50. If you have the aspiration of kind of kicking ass when you're 85, you can't afford to be average when you're 50, and that's just the bottom line. There's no other way to describe that, either through cardio respiratory fitness, strength, or probably even muscle mass to some extent, given its association with strength. So I know it sounds like we're kind of harping on this point, right? That, like, you've, you've got to be strong. You've got to have muscle mass to accompany that strength, probably because at some point when you lose enough of it, you lose the strength, and you've got to have the cardio respiratory fitness. So there was another study that we looked at, Bob, that had the, I think it went out 10 years on the Kaplan-Meier curves, didn't it?

   2. SPSpeaker24:16

      Yes. Let me see if I can pull that up

   3. PAPeter Attia24:18

      Okay. Yeah, this is the one. I thought this was a very interesting study. So you'll have to refresh my memory, but I'm pretty sure this is the one where they looked at men and women, leg strength versus grip strength. They measured these in sort of newton-meters doing, I think, a leg extension and a grip exercise. Correct?

   4. SPSpeaker24:39

      Correct. The leg strength they did in newton-meters, which I, I know that's, that's... those are the units that you like to use in your workouts, and then the, um, [chuckles] the grip strength is in kilograms.

   5. PAPeter Attia24:49

      Okay. So men here, average age about 54. Women about the same, I think 53. So you evaluate people in their sixth decade of life, and then they were followed prospectively for five to six years. Now, remember, this is all cause mortality. So looking at the men's strength, leg strength specifically, it's definitely not subtle, right? So obviously with time, every Kaplan-Meier curve [chuckles] moves down as you go to the right, but the weaker you are, the quicker it goes down. What this analysis showed for the men, if you, if you look at quad strength, basically for every .2 unit reduction in quad strength... And they normalize this for muscle size. It's important to point that out here, I think, is that they, they took their strength metric and they normalized it by muscle size, and they did it in two ways, which I think made this study a little more complicated than I would like, 'cause you get the same answer both ways, I think. But I guess it speaks to the rigor of it. They used actually CT cross-sectional area, and then they used DXA. But when you, when you take that normalized unit of strength per CT area and you reduce that by .2 units, which can seem somewhat, you know... I think for the listener that's not the important point, or DXA reduced by .34 units, you're seeing this increase in mortality, a 26% or a 39% increase in mortality. And with a reduction in grip strength, which was normalized by DXA arm measurement, it's at 23%. All of these were statistically significant. Now, for women, it's worth noting that they were statistically significant, but they had a basically a higher confidence interval or a larger confidence interval, meaning they came close to crossing unity. In fact, Bob, I think it's probably worth including table four in the show notes, 'cause frankly, I find the table to be an easier way to appreciate the statistical relevance of this. So I think the figure's great, because the figure shows you the magnitude of the gaps between it, but it's, you know, nobody can look at these figures and tell what's statistically significant and what is not. But again, I think the point of this is using a pretty rigorous way to quantify strength, normalizing strength by size of muscle, and prospectively following people, we again see this trend. And I think that this goes hand in hand with the previous analysis, which showed us that strength is the more important parameter, which again, I, I don't think we're gonna be able to say that enough today. [upbeat music]

5. 27:39 – 35:44

   The value of deadlifts for stability and longevity when done properly

   1. SPSpeaker27:40

      The importance of deadlifts as an adult. How has your thinking changed on this? I like your history on this one, so maybe even take it back to in school when you were, you were doing powerlifting before it might have been in vogue.

   2. PAPeter Attia27:52

      Yeah. Yeah, long before it was in vogue, one of my best friends in high school, who was also involved in boxing and martial arts, we would go to the Scarborough Campus of the University of Toronto every day and lift weights, and it was... it's still one of the fondest memories I have of what a gym could be like. It would certainly be the... It was certainly not the sunny, warm Gold's in Venice, but it had some of those features, which was old school, lots of iron, nothing fancy. Of course, unlike a nice gym, this was like two stories below ground, so there were no windows. Poorly ventilated, so in the summer it was staggeringly hot. In the winter it was so cold you felt like you were getting frostbitten by touching the iron. And aside from me and my friend, there were no kids there. We were 14, 15, 16 years old, and it was this group of men who to this day I think back and, like, can't believe how strong they were. And most of them competed in powerlifting, and so that sort of got us interested in powerlifting, and that's how we sort of started putzing around with it. And as most people know who are listening, or I guess people who might know who are listening, powerlifting is different from Olympic lifting. Powerlifting is three lifts, the deadlift, the squat, and the bench press. And so yeah, make a long story short, grew up doing a lot of deadlifting, a lot of squatting, a lot of bench pressing. Was always very horrible at bench press, much better at squatting and deadlifting. Fast forward to, I don't know, a few years ago, maybe three years ago, I had an injury where I kind of tore or partially tore one of my obliques. I don't even remember how I did it. I do... I remember it was very stupid, whatever I did. And everything went-

   3. SPSpeaker29:43

      Tearing a phone book?

   4. PAPeter Attia29:44

      [laughs]

   5. SPSpeaker29:47

      [laughs]

   6. PAPeter Attia29:47

      That would be great.

   7. SPSpeaker29:48

      Possible.

   8. PAPeter Attia29:49

      But everything went kind of sideways after that, and I really was never able to fully deadlift again without some discomfort. And so again, this is, now take it back to maybe 2016. I sort of decided, you know what? Maybe the deadlift has reached its point of futility, and maybe I've extracted all I'm going to out of that, and there's no denying what a wonderful movement it is in terms of being a total hip hinge compound movement. But I was like, look, I could probably get most of the benefits of a deadlift doing things that place me under f- less load. And also, again, in the spirit of thinking about longevity, I thought, "Why does one need to subject themselves to twice their body weight or more in an axial load?" So I sort of got away from it. And then I think all that kinda changed when I started DNS, dynamic neuromuscular stabilization, which I started about 18 months ago. And we're gonna have a podcast on this topic, because it's just, there's so much I wanna talk about here. And so actually, I think today we got an email about how we're trying to make some time for this podcast. So we'll definitely... If you're listening to this and you don't know what DNS is, dynamic neuromuscular stabilization, by all means, you should go read about it, but we're gonna have at least, uh, one solid podcast on this. But it was through that process that I realized, actually, the deadlift, for me, was going to be beneficial, not because of the metabolic benefits. I was not gonna be doing Tabata deadlifts like I used to, or even by trying to set records for how much I could lift or anything like that, but rather because it becomes a beautiful audit for everything working perfectly. So I deadlifted this morning, so today's a Monday. I deadlifted on [chuckles] Saturday. I deadlifted a few days before that. Like, I deadlift at least twice a week, often three times a week, both straight bar and trap bar. And Bob, I don't go that heavy. I don't know the last time I... Maybe I've had 400 pounds on one of those b- on the trap bar in the past year, but I usually sort of stop at about 350 to 375. On the straight bar, I'm even lighter, maybe 185. I do a lot of slow eccentrics. I film every single rep of every single set, and I study it, and I send it to Beth Lewis, who is my coach. And we do so much around making this deadlift perfect, and I'd rather take a lightweight and deadlift it perfectly several times a week. And I'm not doing, like, killing crusher sets. Like, I mean, it's, today was four sets of 10, five sets of 10 maybe, and at no point was I, like, past my limit. So again, I can push myself harder doing other things, but what I could get out of doing that deadlift perfectly is, do I have just the right amount of thoracic extension? Do I have just the right curvature in the lumbar spine? Am I activating my glutes? Am I activating my hamstrings? Am I pulling back instead of pulling up? Am I wedging correctly? Like, all of this little stuff translates biomechanically to the activities of daily living that matter to me, like getting up off the floor, picking up one of my kids, lifting a piece of luggage or something like that. And so if I can do the deadlift and it feels right, then I know I'm ready to do everything correctly. And when I'm deadlifting and I feel like, hey, this isn't correct, this doesn't feel right, well, first of all, now I've really learned what that feeling is, and secondly, I've now learned the steps that I can go back and reconstruct what needs to be done. And so one of the things I definitely wanna do is actually put together kind of a video on deadlift and deadlift preparation, because I think that there are probably 10 exercises that I do as a way to get ready to deadlift, and they don't take long. Like, this, my deadlift checklist is, like, 10 to 15 minutes, so it's not so onerous. It's almost like ketosis the way we were talking about it in the past, right? Which is, it's not even clear if it's the ketones themselves that can sometimes be the benefit versus the metabolic conditions that allow you to make them, right? In other words, I'm not even sure how much of the benefit is the actual deadlift versus all of the things you have to do to do the deadlift correctly. And one of the most exciting things, just on this, the last thing I say on this, is it never occurred to me up until a year and a half ago that you could actually deadlift in a way that puts your spine under traction. That's very counterintuitive. You would think that any time you're lifting under an axial load, your spine is under compression. But it turns out when you learn the right positioning and you understand how to create intra-abdominal pressure and you know how to elongate your spine, you can actually deadlift and create traction in the spine actively. And that's why deadlifting is the most important thing I do before I get on an airplane. Because when you're on an airplane and you're sitting there for five or six hours, what you really wanna do is not let your spine be compressed, and the deadlift primes me to then go and sort of maintain that activated form of traction.

   9. SPSpeaker35:14

      Yeah. It's a significant investment, but I would say it's, it's worth it, that you'll bring your hex bar to the gate before your flight-

   10. PAPeter Attia35:20

       [laughs]

   11. SPSpeaker35:20

       ... and pump yourself up and, [laughs] and bang out a few sets.

   12. PAPeter Attia35:24

       I mean, I don't know what it is about the TSA guys. They get so wigged out when you have your hex bar there at the gate.

   13. SPSpeaker35:29

       [laughs] Put that overhead?

   14. PAPeter Attia35:29

       Yeah.

   15. SPSpeaker35:30

       Yeah. [upbeat music]

   16. PAPeter Attia35:31

       Uh, if you're TSA Pre, they don't mind as much, but if you're not TSA Pre, they just lose it.

   17. SPSpeaker35:36

       Sticklers. They're sticklers.

   18. PAPeter Attia35:37

       [laughs]

6. 35:44 – 40:00

   The importance of zone 2 aerobic training

   1. PAPeter Attia35:45

      The next set of clips is from a topic that we've covered on a lot of episodes, and of course, is a very important pillar in this framework of exercise. This is aerobic training, and specifically looking at low-end aerobic efficiency or zone 2 training. This was most recently covered again in our second episode with Inigo San Milan. This is a training zone I spend a reasonable amount of time in. Not as much as I used to when I was a cyclist, and I probably spent, I don't know, 10 to 12 hours a week in this zone. Today, I spend three or four hours a week in this zone, but I still believe this is incredibly important, and I wanna make sure that you understand this. All I'm doing is swimming I'm not doing workouts, I'm not looking at the pace clock, I'm not doing intervals. I literally just get in the water with no agenda other than to get wet and hear the sound of water going by my ears. Probably I'm not even swimming hard enough to get into zone 2, truthfully. I doubt my heart rate's above 120.

   2. SPSpeaker36:47

      That's the next topic.

   3. PAPeter Attia36:48

      Yeah.

   4. SPSpeaker36:48

      That's where I think this is a good segue.

   5. PAPeter Attia36:50

      All right. Very well.

   6. SPSpeaker36:50

      I think this is a good row. If you think about it, and you can talk about it, but I think that's one of the things is like a governor putting a, a rate limiter on your performance when you do zone 2. That it, it's almost like for a lot of people it is... For me, doing this reminds me kind of stillness. Although I might read on the bike or things like that, but can you talk about zone 2 importance and how your thinking has changed on that?

   7. PAPeter Attia37:11

      Yeah. When I stopped riding a bike with a purpose, which was for me a time trial, so that would've been late 2014, early 2015, I kind of really just stopped doing any low intensity aerobic training. So anyone who does ride a bike or swims a lot has plenty of that activity in them. So even if you're training for the 200 meter individual medley, which is a race that's very short, very quick, and very painful, you still put in hours and hours a week of aerobic based training. Similarly, if you're training for a one-hour all out time trial, you still put in hours a week of low-end aerobic based training. But when I stopped doing that, I was like, "Well, I don't need to do this anymore." And I went from cycling to rowing and running, and I was sort of obsessed with just being as efficient as possible, so everything was all out. I mean, I was... If I was running, it was gonna be a six-minute mile. It wasn't [chuckles] gonna be a nine-minute mile. I think especially through the interactions that I had with Inigo, who I met about a year before I had him on the podcast, which was just recently, it was sort of meeting him and kind of going back through the literature on that type of training and the benefits that it could have, both from the standpoint of metabolic benefits such as glucose, insulin dependent and insulin independent glucose, mediated disposal, looking at just sort of mitochondrial function, mitochondrial health density, and then looking at sort of the, the sort of neurotropic factors, the BDNF secretion that can come from this type of activity. I mean, all of these things were just pointing towards this was a glaring hole in my training that I needed to get back. And so that has been great. And like you said, I mean, one of the things about zone 2 that I really enjoy is it's just not that hard. [chuckles] You know? Like frankly, sometimes it's just nice to get on the bike, and I probably spend three or four hours a week doing it, and that is my time to listen to podcasts and audiobooks. And I really enjoy it. I can't wait to get on that bike. As sort of boring as it seems to be sitting on a stationary bike for that long, there's never been a day when I've been like, "I don't feel like doing this." I just, I always look forward to it, and I think in large part it's because I also get to combine it with learning, which you wouldn't be doing if you're out there crushing intervals. And not that there's something wrong with that, I think each of these things has its time and a place, but I think that we can do zone 2 our entire lives, we can do it safely, and it just yields enormous dividends. [upbeat music]

7. 40:00 – 44:21

   The most effective ways to engage in zone 2 exercise

   1. PAPeter Attia40:00

      Your question, if I recall, was if you wanna do your zone 2 training at home, what's the best type of device to do it on? I don't think there's a best device, but I would say it's one where it's very easy to reproducibly produce the same output. So I am hugely fond of a bicycle because it has a very clear metric that I can adjust, which is the wattage. Watts are super easy to track. I'm riding on a bike that is an ergometer, so I put my road bike on a device called a Wahoo KICKR, and it is hooked up to a computer where I'm telling it the numbers of watts that I want, and it's putting that resistance into me, and I generate it. Now, my wife conversely likes to ride a Peloton. I don't know why. I think it's the worst bike on the face of the earth. But on the Peloton it works a little bit different, which is she goes into, like, a mode where she's not doing a class, but she basically sets the resistance with a little knob, and then the amount of RPMs that she can put to it spits out a wattage. But it's actually in my mind a little harder 'cause she has to kinda control... Like, she has to be titrating her cadence to stay the same so that she can hit a wattage number. So it's the difference between being in erg mode and spin mode. But the point is, regardless of how you do it on a bike, wattage becomes the metric that matters. We, of course, are always measuring heart rate as well, and we'll talk about this in a second in terms of how you, you tweak it. Treadmills are also a great way to do this. In my experience, unless you are a really good runner, which is to say you're very efficient at running, for most people, running gets them out of zone 2 a little too quickly. So w- for treadmill with our patients, we prefer brisk incline walking. Most treadmills will go up to 15 degrees, and we generally start people between 10 and 15 degrees, somewhere between two and a half and three miles per hour, maybe less. And again, it's very empirical. It's sort of how quickly can you figure out where somebody is? By those two metrics, I have a very clear sense of my zone 2. I know exactly how many watts my zone 2 is. I also know what heart rate I should expect to see, and if I'm vastly outside of that, there's usually a physiologic reason, and I have to make an adjustment on the wattage. So if my heart rate is significantly higher than that, it might mean I'm a little bit sick, dehydrated, something else is going on, and I might have to back off to get the heart rate down, even if it means bringing the wattage a little bit below. And I'm checking my lactate every single time I do this, and I do it four times a week. We'll discuss frequency. Same thing on treadmill. I know on a treadmill exactly what incline, exactly what speed, and what heart rate, and it's a comparable heart rate, too, on the bike. That's an easy way to sort of make that happen. The other thing my wife loves is a rowing machine. Now, I'm not fond of the rowing machine for zone 2. I like the rowing machine for zone 5, but that's because I'm not a very good rower. So again, my wife's a better rower than me, and she has better form than me. Someone like Beth Lewis, who we've had on the podcast, who's an amazing rower, she's more efficient. She can get a zone 2 workout on the rowing machine. I love rowing, but it's just cycling for me is second nature. Cycling is a very efficient thing for me to do. I'm not hugely fond of ellipticals personally, but again, if you have one that works for you where you're able to get your heart rate high enough and you're able to move quick enough, then great. The key is how much energy do you have to put into maintaining a sustained dose? And that's the biggest challenge, Bob, with zone 2, is you don't want it to be vacillating. And that's why ultimately I love being on an Erg mode of a bike, which is I don't actually have to think about it. It's putting 200 watts to my wheel no matter what I do. Even if I slow down or speed up, it's just always keeping the watts the same. Frankly, I can just tune out and listen to podcasts and audiobooks, which is what zone 2 is for in my book. [upbeat music]

8. 44:21 – 51:58

   Zone 5 training and VO2 max

   1. PAPeter Attia44:21

      The next set of clips look at another pillar in my framework of exercise, which is now that upper-end aerobic verging on anaerobic exercise. So we sometimes talk about this as zone 5, but again, I would be less concerned with the terminology. The zones really are a function of the underlying system that you're referring to, whether you're talking about a heart rate-based training or a power-based training. I think of zone 5 as basically your VO2 max training, and I think a lot of people sometimes spend too little or too much time in this zone, and we want to kind of help you understand what that sweet spot might look like, assuming that you're not training specifically for athletic events that require unusual levels of fitness around that energy system. But again, if you're really just talking about being the fittest, healthiest person you need to be to be kind of a kickass 90-year-old, then I think we don't need to be spending quite as much time there as you might think to harness the benefits. So in these clips, I'm gonna talk about how I train there and how I think about VO2 max. Now, we talk about VO2 max in AMA 27, and that's where we're gonna talk about how the benefits appear to comparing someone of low fitness to elite fitness with respect to these metrics. And it's kind of staggering. The difference between someone at the bottom 25% of VO2 max versus someone at the top 2.5% is about a fivefold difference. So this shows the importance of VO2 max and why I think you ought to be spending more time there. [upbeat music]

   2. SPSpeaker45:56

      We've got a zone, zone, wait for it, 5 question, not 2. "What is Peter's approach to zone 5 training? What about other anaerobic training protocols?"

   3. PAPeter Attia46:08

      I love this. So my zone 5 is mostly done on my StairMaster, which is my absolute favorite piece of equipment that's not a bicycle.

   4. SPSpeaker46:17

      [chuckles] Other than the elliptical?

   5. PAPeter Attia46:19

      Yeah, I can't stand the elliptical.

   6. SPSpeaker46:20

      [chuckles]

   7. PAPeter Attia46:21

      So basically, my zone 5 workout, which I really only do once a week, is three minutes of zone 2 with one minute at VO2 max. Because I know what my VO2 max is, I know how to convert it into Mets, which is VO2 max divided by 3.5, and the StairMaster allows you to work in watts and Mets. So basically, I'm doing three minutes at my zone 2, and then I go one minute at what my VO2 max is, which truthfully is quite difficult to hold your VO2 max for one minute, and then right back to three. My recovery is then the three minutes at zone 2. And so that four-minute pattern I just repeat for 20 to 30 minutes, and I usually do that on the tail end of a zone 2 workout. So that's kind of my longer aerobic day. Other workouts that I liked when I'm outdoors on my bike, I, I also like doing kind of a more VO2 max training type ride, which would be kind of like a four minutes at, call it 125% of FTP, functional threshold power, followed by four minutes recovery. So one-to-one work rest, but obviously at a lower intensity than the three-to-one rest to work that I just described. So yeah, there's lots of ways to hit zone 5, and it's a very important zone as well. My view is most people spend too much time there and not enough time in zone 2, though.

   8. SPSpeaker47:51

      I've got a few follow-up questions, which it'll give you more time, too, on this.

   9. PAPeter Attia47:54

      I went almost to my two minutes on that one. I was, like, staring at my clock.

   10. SPSpeaker47:59

       One's, I think, simple. So the StairMaster, are you-- Is it a StairMaster, or is it, I don't know if it's called a stair climber. Do you have the one where it's, like, literally you're going up steps, or is it the one where the, you just have, like, two levers and you're pushing them back and forth?

   11. PAPeter Attia48:12

       Oh, sorry. No. Mine is, like, the fancy gym one where it's like an escalator of steps.

   12. SPSpeaker48:16

       The Jacobs Ladder? Is that what it's called?

   13. PAPeter Attia48:17

       No, no, no, no, no. It's not a Jacobs Ladder. It's, it's a series of eight-inch steps that roll up and down a machine. So the higher the intensity you set it, the less resistance is in those steps and the faster you have to go to not fall off the back. So if I set it to, like, eight Mets, it's moving quite-- it, there's actually quite a bit of resistance, so I can step quite slowly without falling off. When I set it to, like, 20 Mets, it feels like there's no resistance, and I'm running up the stairs to not get thrown off the back.

   14. SPSpeaker48:51

       I think we could do a podcast on a lot of this stuff, VO2 and, and all that other stuff. But one of the things that sticks out to me, 'cause You know when you got like a coach or anybody and they, they, they want you to give 110% and you think like, "What the hell does this... You know, I can give 100%, maybe."

   15. PAPeter Attia49:05

       [laughs]

   16. SPSpeaker49:05

       But when you're talking about your VO2 max and you're saying I'm, you know, I'm going at 100%, I think some people might just think like, "Oh, this person... You, you must be going all, like balls to the wall, all out."

   17. PAPeter Attia49:16

       No, definitely not.

   18. SPSpeaker49:17

       However, when you're looking at like what's my workload to my VO2 max, you can actually, you can exceed 100% of your VO2 max-

   19. PAPeter Attia49:24

       Absolutely

   20. SPSpeaker49:24

       ... in terms of the work you're doing, right?

   21. PAPeter Attia49:26

       Right. And Alex Hutchinson, who is gonna be on the podcast very soon, writes about this very elegantly in his book Endure. Basically, the limits of human performance in terms of, quote-unquote, "going all out" is about 10 seconds. So really no human has the potential to go all out for 10 seconds. You might think you are, but you're not.

   22. SPSpeaker49:45

       Wait, wait, wait, wait. But I, I, I take spin class. I've taken spin classes before, and I'm going all out for like [laughs] 80% of it, you know? Or at least the, the instructor wants me to go all out-

   23. PAPeter Attia49:55

       Sure. Sure. Yeah

   24. SPSpeaker49:56

       ... for about 80%, right?

   25. PAPeter Attia49:57

       The instructor, the instructor is playing games with your mind, and if that helps you, so be it. But look, you only need to look at the difference between a 100-meter and a 200-meter sprint. So take the best explosive athletes on the planet, and even by the time Usain Bolt is running the 200, he is slowing down in the second half of that race. The force with which he's able to hit the ground in the second half of that race is slower. He can go faster in the second half because he gets a flying start. But the 100 meter, which is basically a 10-second race, is about the true limit of what all out means. So I even find this interesting when you consider two variants of Tabata. As you know, there's the 20/10 Tabata and the 10/20 Tabata, and you and I both have air bikes, which have, you know, which are, are great tools for doing that. When I go through cycles of Tabata, which these days I'm not, I'm focusing much more on zone five workouts on both m- the rowing machine, which I didn't get into, and also in the stair machine. But sometimes I just do like a couple Tabatas a week. I mean, anybody who's tried both knows you can go so much harder for the 10/20 than the 20/10. The 20/10 is generally favored because that's the one that was studied by Izawa and Tabata. Fun fact, by the way, Tabatas are not named after the guy who developed the protocol. He was the guy that wrote the paper. Izawa developed the protocol. They should be called Izawas. So the problem with a, quote-unquote, "20/10 Tabata" is whether consciously or subconsciously you're actually pacing yourself to complete it, which is what it is, but I, I think it actually poses a little bit of difficulty.

   26. SPSpeaker51:37

       Okay. I'm surprised you don't actually just say, "I do Izawas," and then have people-

   27. PAPeter Attia51:42

       Have people look it up?

   28. SPSpeaker51:43

       ... look at you and... [laughs] Yeah.

   29. PAPeter Attia51:46

       Dude, Mondays and Fridays, Mondays and Fridays is a, I just do Izawas.

   30. SPSpeaker51:50

       Yeah. [laughs] See people nodding their head. [upbeat music]

9. 51:58 – 1:03:09

   A primer on VO2 max

   1. PAPeter Attia51:58

      So with that, let's just start with sort of something you've already alluded to. Let's explain what it is, talk about how much it matters, and then kinda get into some examples. So let's start with a term that many people have heard before, but I, I don't think most people understand what VO2 max really means. And eventually we're gonna talk about running efficiency and lactate threshold, and we're gonna get into all of this stuff, but let's, let's make sure people understand what VO2 max is, both in an absolute term and then in a manner that we normalize it by weight, and what it is and what it isn't, how it's measured, how it matters, and maybe we'll even talk about some notable exceptions.

   2. SPSpeaker52:33

      So VO2 max is the one physiological parameter that anyone who's involved in endurance has heard of and has some sense of. The first order analogy is it's kind of the size of your engine. Physiologically, VO2 max is telling you how quickly you can take oxygen from the air into your lungs, get it into your blood, pump it to your muscles, and then have your muscles use it in the metabolic processes that will provide energy to move you to do whatever you wanna do. So it's a rate. It's how much oxygen per unit time can you process absolutely flat out. Now, the sort of backstory here is it was first sort of discussed or measured in the 1920s by a guy named A.V. Hill, who was actually a very good runner. The observation that he made is if you have someone, you g- you ask someone to go out and run at a, at a gentle pace, they'll consume, let's say, two liters of oxygen per minute. Then you tell them to speed up. Now they're, they're doing three liters of oxygen per minute. Tell them to speed up again, and now they're going pretty much, maybe not as fast as they can, but they're going fast, and they're using four liters of oxygen per minute. So you tell them to speed up again, and you measure it and you're like, "Oh, they're only using four liters of oxygen a minute just like last time." And you say, "Well, speed up again," and they're still just using four liters of oxygen a minute. There's a plateau. There's a point at which even though you're working harder, you're not using any more oxygen. And so this plateau looks like it's a physiological limitation, and it probably is in, in some sen- you know, it's a controversial thing. But basically, you've reached a point where no matter how hard you push yourself, you can't get more oxygen. And so you can still go faster 'cause you're starting to use other forms of energy. But this is the limits of your aerobic system. This tells you... What it tells you, uh, we, we can get into. [laughs] It, it's not clear what it tells you. It tells you exactly what I just said. It tells you how much, how much oxygen you can use. Does that tell you exactly how fast you can run? No. There are a lot of other factors. But it's, that tells you what sort of aerobic engine you have to play with.

   3. PAPeter Attia54:30

      I remember in high school, I mean, we would sort of talk about, well, which athletes have the highest VO2 max? Is it the Norwegian cross-country skiers? Is the professional runners and cyclists and things like that? But people are usually used to hearing these numbers reported not in liters per minute, but in milliliters per minute per kilogram. So give an example so people understand those differences, 'cause we usually talk about the outliers as a number that's a bigger number than two liters or five liters. It would be, you know, sort of 75, 80 milliliters per... Just explain to people how, how those are different.

   4. SPSpeaker55:07

      Sure. So I'll use my own numbers. I, when I, you know, typically when I was tested, I could get about a little bit more than five liters per minute, so 5.1, 5.2, if I remember correctly. Now, if you compared me to a rower, the rower would make me look pathetic because the rower would be using seven liters a minute or, or more. But the rower is also huge, twice my size or whatever. And so that doesn't necessarily mean that that rower is better at using oxygen for me because the rower has way more muscle, and so the rower is-- the amount of oxygen reaching any given muscle cell may be lower. So if you wanna compare apples to apples between athletes of different sizes, you divide... at least for a crude approximation, you just divide by weight. And so the numbers we usually hear are rather than liters of oxygen per minute, it's milliliters of oxygen per minute per kilogram of body weight. So for me, five liters of oxygen per minute works out to something like 80 milliliters of oxygen per minute per kilogram of body weight. There's a whole rabbit hole to go into is to say, "Well, why are we dividing by whole body weight?" Because, you know, there's a bunch of things like skeleton and organs and stuff that don't scale.

   5. PAPeter Attia56:24

      The adipose tissue doesn't matter. I mean, you could argue a better comparison would be total liters per minute divided by lean mass divided by time or normalized to time, and then you're, you're at least getting the, the metabolically active tissue, presumably.

   6. SPSpeaker56:39

      Yeah. And there's papers where they do things like let's divide by weight to the power of zero point six eight or point seven, which is another way of getting-- effectively, it's a way of approximating just the lean mass, the metabolically active tissue. And you can go down that rabbit hole, but I, I suspect you'll wanna get to is it's like at a certain point, it doesn't matter that much anyway, so we don't need to... You can't just measure someone's VO2 max and know how fast they're gonna race. So it's, it's, it's useful, but it's not-- it, it re- especially for comparing between people. Now comparing within yourself, it tells you something if, if you've increased or, or if your VO2 max has decreased. But in that sense, it doesn't matter what you're dividing by.

   7. PAPeter Attia57:18

      I remember there was a guy that I used to ride with, and this was not that long ago, maybe five or six years ago when I was still, you know, somewhat competitive, at least with myself. Actually, it's funny, my number was just like yours, except I was heavier. So I was about five point one to five point two liters, but I weighed more, so that worked out to about 70 mils per mig per kig was my VO2 max. His was 55 to 60, but there was never a day that I could ride faster than him, not one. There simply... And, and I always felt like, although we did the test so many times, I kept feeling like the machine must have been broken on him. Like I knew my 70 was about right because I'd been tested so much, and that was lower than it had been when I was younger, so it seemed appropriate. But I was always convinced that that-- there's no way he's only 55. The reality of it is he may well have been, and he may have simply been a far more efficient athlete, which we're, we're gonna get into. Before we get to the story of Oscar Svendsen, let's talk a little bit about historically what people have believed the limits are of VO2 max.

   8. SPSpeaker58:23

      We don't even have to go very far historically to get into a whole mudslide of confusion and debate and disagreement. There's a lot of places along the way that could, in some circumstances, be the bottleneck. Normally, people tend to assume that what is it that causes VO2 max to plateau is essentially what, w- I think what we're talking about. And just one thing I should add here, it's like, why is that interesting? It's because you think, well, if you wanna measure endurance, just have someone run a mile or whatever, you know, as hard as they can. But any test like that depends on motivation, depends on whether you pace it right. There's all these factors that come into it. The nice thing about VO2 max is that in theory, it's independent of motivation. That's why scientists like it, because it doesn't matter if the subject doesn't really care about the study. If you see a plateau, you know that's a property of their body and not a product of whether they were excited about the study. So the question is, this plateau, what is it that causes it? And it could be in the lungs, it could be the heart, it could be the circulation, it could be the muscle's ability to extract it. I don't wanna pretend that I know the answer because it's still controversial. The, the picture that emerges is that almost every part along this cascade is engineered more or less to what it needs to be. And so if you perturb any of those elements, you can get limitations. So for example, the conventional wisdom is that your lungs are not a limitation. You can always breathe enough in. And so then the question is, can you diffuse enough oxygen from your lungs into your bloodstream and so on and so forth? There are situations where-- and it's been for decades, it's been conventional wisdom that the lungs don't respond to training because they're overbuilt. There was just a paper published, a big review in the last month or two, arguing that, you know, in some cases, the lungs aren't overbuilt, and one of the situations is highly trained endurance athletes. They can be limited by their ability to get enough oxygen in. And you can also run into situations where an athlete is so fit, their heart is so strong, it pumps blood past your lungs so quickly that it doesn't have time to fully stock up on oxygen. You get something called exercise-induced arterial hypoxemia. So this, this is usually an issue at altitude, but in elite endurance athletes is actually about half of them exhibit it even at sea level. So they're already running into a limitation just in getting oxygen from their lungs to their bloodstream. And then at every stage of the way, there can be limitations if anything is knocked off kilter, and certainly right down to the ability of the muscles to first extract the oxygen from the bloodstream and then the, to make use of it metabolically in the, in the mitochondria. So it's-- there, there isn't one single answer, which is why you get these debates because everyone is cons-- "I have evidence that this is the limit." It's like, "Yeah, but I have evidence that this is the limit and that's the limit, and they're all the limit."

   9. PAPeter Attia1:01:05

      Yeah, I've always wanted to see the experiment where you took a group of athletes, maybe this has been done, you run them all to max, and then you reduce the FiO2 of the incoming oxygen. So normally we do it with room air, so you're getting, uh, the fractional inhalation of oxygen is 21%. And the way, of course, just for the listener, the way these things work is the way they're calculating how much oxygen is being consumed is they're measuring the concentration of oxygen on the way out, so you're calculating the delta. And so I've always thought, well, wouldn't it be interesting to start selectively dropping FiO2, twenty-one percent, twenty percent, nineteen percent, eighteen percent? Now presumably, if the lungs aren't the limitation, you should still see the same absolute delta, and you could at least start to eliminate one of those variables, which would be FiO2 and capillary exchange, and then you start pointing to some of these other variables. A- again, I'm sure somebody has done this experiment, but I don't know what it yielded.

   10. SPSpeaker1:02:03

       Probably not with the, the fine-tooth comb that, that you're suggesting. People have compared twenty-one percent to ten percent or whatever, and fifteen percent. It, I mean, it's interesting when you go to altitude or the equivalent, when you reduce the amount of oxygen, funny things happen. Like, the first thing you would think would happen is, like, you can't get enough oxygen, so you're gonna b- go anaerobic sooner, you're gonna produce more lactate, and yet the opposite happens. There's something called the lactate paradox. If you try and exercise to exhaustion at lower levels of altitude, you actually give up when your lactate levels are lower than you would at sea level, and there's debate about what causes this and even whether it's a real thing. But the picture that makes sense to me is, is that these things are not just about how much oxygen is making it to the muscle. It's also, like, what is your brain oxygen level? And so you're, you're getting these other circuit breakers that are starting to come down that aren't even on this path from mouth to lungs to blood to muscle. There's other factors that are saying, "Whoa, wait a second, oxygen's getting a little low, so we're gonna actually cut off the supply to the muscles or reduce it in order to make sure that we don't get stupid." [upbeat music]

10. 1:03:09 – 1:07:55

    Stability—the cornerstone upon which all exercise and movement relies

    1. PAPeter Attia1:03:09

       This next clip is going to focus on stability. As I mentioned at the outset with Beth Lewis and Michael Rintala, we filmed a bunch of instructional videos to go with this. I can't recommend them enough. It's one thing to hear us talk about these things. It's quite another thing to see the exercises and be able to do them yourself. [upbeat music] Stability is the cornerstone upon which you do everything. It is the cornerstone upon which your strength is delivered, your aerobic performance is delivered, and your anaerobic performance is delivered, and it's the way that you do so safely. So stability is a way that we transmit force from the body to the outside world and vice versa, from the outside world to the body, in the safest manner possible across the muscles which are designed to carry that load, as opposed to seeing the dissipation of force across joints that are not fit to do so. So for example, when you're picking something up, let's say you have to pick up something and it weighs sixty pounds. Well, you have to exert sixty pounds of force on the world around you. That's, Newton's laws tell us that that's what it means to pick up sixty pounds. The idea is you want all of that sixty pounds to be transmitted from your muscles to the ground lifting this thing up, and you don't want anything dissipating out your back, out your knees, out your hips. And while we're, most of us are born with the ability to do that naturally, it generally gets lost by the time we're in grade school in response to many things, but probably chief among them is a relative lack of activity and a relative abundance of sitting. And when I look at my two-and-a-half-year-old move, it's a perfect clinic in force transmission safely across the body. When you look at me move prior to sort of becoming obsessed with and schooled in these disciplines of, as you mentioned one of them, dynamic neuromuscular stabilization, or DNS, it's always a little bit of an inefficient way to get things done, and it results in a lot of force leakage or seeping out around my scapula, my elbow, my knee, my back, my hips, and this is sort of one of the root causes of a lot of the chronic injuries a lot of us have. So stability then is probably what I think of as the foundation upon which everything should be done vis-à-vis exercise. Just yesterday, I was actually talking to a patient, and she was asking me if she needed to do DNS or if she could continue to work on the Pilates that she has been doing for many years. And my response was that I think a great Pilates teacher is already teaching many of these principles. So I think this is somewhat discipline agnostic, but it's heavily dependent on the practitioner and the student. So I've seen really good Pilates teachers who, even though they're using a very different vocabulary than the one that I use or that the DNS practitioners use, the results speak for themselves, and those patients do have the correct patterns of movement. They are able to get air fully into their lungs. They're able to get their diaphragm low into their abdomen. They're able to flatten out their pelvic floor, generate concentric, robust intraabdominal pressure that stabilizes every aspect of them. There are other people who either the teacher doesn't have the skill to do that, or the teacher does, but it's just not being presented in a way that the student can understand it. And so this is also one of those things that's iterative, and I think one should always be searching for this. So postural restoration, PRI, DNS, Pilates, these are all different ways that one can come about trying to learn these principles. I think unfortunately, of the four pieces of exercise we're gonna talk about, this is the one that probably will take the most tinkering for people to find the right type of practitioners Probably sometime next year, Bob, as you know, we are going to start to put together some material on this for people outside of our practice. Currently, all of the work we do on this front, we've put together many video courses. Those are exclusively for our patients at this point. But as our knowledge expands and our footprint in this space expands, my hope is that we are able to start to create digital curriculum on this type of stuff that can help people who, again, don't have access to somebody. [upbeat music]

11. 1:07:55 – 1:14:08

    Peter’s current exercise routine

    1. PAPeter Attia1:07:55

       We'll end this week's episode with a clip from one of our recent AMAs, I believe episode 32, where I talk about the macro structure of my current training routine. As we come to this end, as I want to mention in the intro, it's the first time we've done this, so we'd really like to hear your feedback, positive and negative. Is this something you want to see us do again with other topics? If so, maybe even suggest some of the topics you'd like to hear. And if not, please be honest with us and tell us not. As I said, it's a lot of work to do this, and we only want to do this if people find this valuable. So thanks so much. [upbeat music]

    2. SPSpeaker1:08:30

       I thought it might be helpful for people before we get into some of those specifics, just what does your current exercise routine look like each week? I know it's always changing, but if you can give people a rough overview, I think that will be helpful as we get into some of these other questions.

    3. PAPeter Attia1:08:45

       Yeah, I mean, the actual macro structure of what I do has not changed much in the last year. The microstructure has changed a lot, meaning the exercises have changed a lot. But the macro structure is that on, let's see, Tuesday, Thursday, Saturday, Sunday are cardio days. So Tuesday, Thursday, Sunday are zone 2. Saturday is either a zone 2 followed by a zone 5 as kind of a separate workout. So each of those are 45-minute zone 2s and then kind of like a 30-minute zone 5 as a separate workout that's done almost immediately after. So basically getting out of bike clothes and putting on stair climbing clothes. Alternatively, I might just do a longer bike ride on Saturday and make it more of an anaerobic workout. Uh, then from a lifting standpoint, it's Monday, Wednesday, Friday, Sunday is lifting. And about, I don't know, nine months ago, I switched to an upper body, lower body split. I used to lift three days a week and do upper body, lower body every day. So each day I was doing kind of pushing, pulling, and hip hinging. And now the lower body component I think is Monday, Friday. The upper body is Wednesday, Sunday. And I always lift after doing cardio because I think the reverse has been demonstrated to erode strength training gains.

    4. SPSpeaker1:10:11

       Peter, what happens if you miss a day? Because I noticed you didn't say day one, day two, day three. You were very distinct on the days of the week. I know you typically don't miss a day, but if you miss Wednesday, do you just scrap those exercises and then just continue with your program? Or are you trying to make up in the interim?

    5. PAPeter Attia1:10:27

       No, like yesterday, Sunday would have been a, a ride followed by lift day, but I was on the track the whole day and I knew, you know, I knew that in advance. So I just ended up doing that lift on Saturday, but obviously was shortchanged on the zone 2 for yesterday. So I will pretty much will never compromise a lift. I will always get those four lifts in during the week no matter what. And sometimes it just means moving the days around or doubling up on a different day.

    6. SPSpeaker1:10:56

       And what about timing? Do you have a preference morning, afternoon, evening? Is that flexible as well within kind of your schedule?

    7. PAPeter Attia1:11:03

       A little more flexible on weekends, but Monday through Friday, pretty much no flexibility. Those lifts have to be done first thing in the morning. And not first thing in the morning. So morning routine is kind of more about the kids and stuff like that. But once they're out the door to school, it's around 7:15, 7:30, that's when I'll typically lift. 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: 1:14:08