Peter Attia MD276 ‒ Special episode: Peter on longevity, supplements, protein, fasting, apoB, statins, & more
CHAPTERS
- 0:00 – 8:08
Why Peter doubts living to 120 or 150
The host explains this special Q&A format, and Peter explains why he lacks confidence in biohacking one's way to 120–150 years. He says no tools exist today to reverse the underlying biology of aging, so people should use current prevention tools as a hedge.
- •Peter has seen no evidence that the underlying processes of aging can be reversed
- •Living another 70 years at age 50 would require a way to halt or reverse aging within about a dozen years
- •He sees a big mismatch between real science and what the press and social media portray
- •Acting on today's tools for prevention is a hedge against long odds of a miracle
- 8:08 – 15:06
The Four Horsemen, the marginal decade, and what could still help
Peter discusses which diseases could realistically be delayed, with ASCVD the clearest candidate through very early prevention. He says the focus should be compressing late-life frailty in the marginal decade, and names mTOR inhibition as a promising incremental advance.
- •ASCVD could be delayed with ultra-primary prevention, such as keeping apoB at 30–40 mg/dL
- •Following the book's steps could plausibly add a decade or more to life
- •The goal is staying physically and cognitively robust in the marginal decade, as in the centenarian decathlon
- •Pharmacologic mTOR inhibition is promising because it worked in animals even when started late
- 15:06 – 17:44
Prospects for the next generation
Asked about a ten-year-old's potential lifespan versus his own, Peter says he cannot predict the pace of innovation such as epigenome modulation. He notes that younger people also face a longer horizon for catastrophic risks like nuclear war and biological terrorism.
- •Peter has children aged six, nine and fifteen and thinks about their runway versus his
- •Selective, high-precision modulation of the epigenome is the breakthrough he's most interested in
- •He ranks biological terrorism as possibly the greatest threat to the species
- •Kids have as much time to meet catastrophic risks as to benefit from breakthroughs
- 17:44 – 27:19
The lack of aging biomarkers and the risk/reward framework
Peter explains that interventions like nutrition, sleep and drugs like lisinopril have feedback biomarkers, while geroprotective compounds do not. He recounts his past fasting protocol as an example and describes his gold coin/penny and train/tricycle risk-reward matrix.
- •Weight, glucose or blood pressure give feedback on dosing; geroprotection has no equivalent
- •Peter doesn't know whether his seven-to-ten-day fasts helped, though they cost him about twenty pounds of muscle
- •Diagnostics and biomarkers are an unsexy area that attracts little investment
- •The matrix places interventions by risk (low to high) and reward (penny to gold coin)
- •He walks patients through this framework when they show long supplement lists
- 27:19 – 36:50
Peter's supplement list
Peter reluctantly details the supplements he takes, with brands and doses, and the rationale for each. He treats several to biomarkers such as red blood cell EPA/DHA and homocysteine, and describes his night-time stack and travel use of phosphatidylserine.
- •Fish oil dosed to about 12% red blood cell EPA and DHA
- •Vitamin D at 5,000 IU, magnesium from several forms, and methylated folate and B12 to keep homocysteine under nine
- •B6 lowered to 50 mg three times a week; baby aspirin described as a soft call
- •Night stack of ashwagandha, glycine and magnesium L-threonate
- •Disclosed that he is an investor in and advisor to Athletic Greens (AG1), which he takes with a Pendulum probiotic
- 36:50 – 40:40
How his regimen has changed in the past year
Peter lists what is new or different from a year ago, including the Pendulum probiotic, which he is testing against his own glycemic markers. He also describes returning to ashwagandha and switching fish oil brands.
- •Pendulum probiotic is new, chosen for a small trial showing a 0.6-point A1c drop and about 30% lower glucose AUC
- •He is about to run blood tests to see if it changed his own markers
- •Ashwagandha was restarted using a more potent version
- •Fish oil switched from Nordic Naturals back to Carlson because of broken capsules
- •Aspirin and vitamin D use has been on and off
- 40:40 – 47:11
Lowering apoB: nutrition limits and Peter's three-drug approach
Peter explains that exercise doesn't meaningfully move lipoprotein risk, nutrition has modest effect through carbs and saturated fat, and pharmacology is the potent lever. He describes his apoB target of 30–40 and his regimen of Repatha plus Nexlizet, and why he avoids mega-dose statins.
- •Cutting carbohydrates lowers triglycerides and cutting saturated fat upregulates LDL receptors
- •His baseline apoB is 90–100 mg/dL, so he uses a PCSK9 inhibitor and bempedoic acid/ezetimibe
- •Bempedoic acid is a prodrug that inhibits cholesterol synthesis only in the liver
- •Rosuvastatin reaches about 85% of its apoB effect at 5 mg, so higher doses mostly add side effects
- 47:11 – 54:01
Statin side effects, PCSK9 pricing, and the Lp(a) drug pipeline
Peter addresses long-term use of statins, naming three documented side effects and noting that cost may force younger people toward statins. He then covers falling PCSK9 prices and an antisense Lp(a) drug whose phase three secondary-prevention trial will decide approval.
- •Statin side effects include muscle aches, elevated liver tests and insulin resistance
- •Pitavastatin and rosuvastatin are probably the best places to start, but response is individual
- •PCSK9 inhibitor price has dropped over 50% in eight years, with a six-month shot on the way
- •The Lp(a) drug eliminated Lp(a) in phase two and is now in a secondary-prevention phase three trial
- •Rule of thumb for drug development is a decade and a billion dollars
- 54:01 – 56:03
Why there is no good and bad cholesterol
Peter explains that LDL and HDL are lipoproteins that carry cholesterol, and that cholesterol itself is the same molecule in both. He says lab values reflect cholesterol content (LDL-C, HDL-C), and that speaking of good and bad cholesterol is a red flag.
- •LDL and HDL are carrier particles, not cholesterol
- •Lab panels measure the cholesterol content within them
- •LDL traffics cholesterol into the artery wall where it is retained and oxidized
- •A doctor who says good and bad cholesterol is showing a lack of understanding
- 56:03 – 1:04:51
Why nutrition research is hard and what principles hold
Peter explains that nutrition research is difficult because both humans and eating are complex, and long controlled human trials are nearly impossible, so the field relies on epidemiology. For patients he stresses energy balance and sustainability over dietary tribes, and cautions against inferring diet from long-lived populations.
- •Rhesus monkey caloric restriction studies took over 20 years and were hard to interpret
- •Controlled human studies can't last long, so nutrition relies on epidemiology
- •Energy balance is the most important parameter for metabolic health
- •Patients with profound insulin resistance respond better to carbohydrate restriction in his experience
- •Long-lived populations eat diverse diets, so diet alone likely doesn't explain longevity
- 1:04:51 – 1:06:17
Why Peter stopped prolonged fasting
Peter says he no longer does long fasts, partly because he used to do them while traveling and no longer travels. More fundamentally, he sees no clear benefit or biomarker to justify the cost, though he would reconsider with evidence.
- •He used to fast only while traveling
- •He lacks a biomarker showing a long fast rewrites negative processes
- •He reserves the right to change his mind
- •The cost currently seems too high
- 1:06:17 – 1:11:44
Optimizing protein intake
Peter says protein targets depend on muscle mass, and he finds the data on higher mortality with high protein in people under 50 unconvincing. He describes entering middle age with enough muscle and shares his own 150–180 grams per day, largely via venison jerky.
- •Overweight but well-muscled people in a deficit can relax protein to about 0.6–0.7 g per pound
- •Under-muscled people should keep protein high while losing fat
- •He attributes under-50 mortality associations to caloric excess and confounders
- •Muscle gained early protects against frailty later
- •He eats 150–180 g daily in about four hits, using venison jerky sticks (he's an investor in the company) and whey
- 1:11:44 – 1:14:47
Wearables: Morpheus for Zone 2 training
Peter describes his current favorite device, Morpheus, which uses heart rate data and morning inputs to produce a readiness score and training zones. He is comparing its predicted heart rates against lactate to see whether patients could use it for Zone 2.
- •Morpheus uses a chest strap and forearm strap plus a two-minute morning measurement
- •He enters sleep data from his Eight Sleep
- •For six months he has compared its predicted Zone 2 heart rate to RPE and lactate
- •It tracks better than he expected
- •He wears it only for Zone 2 and VO2 max work because he dislikes heart rate monitors
- 1:14:47 – 1:24:16
CGMs, continuous blood pressure, and future wearables
Peter says he still uses CGMs widely with patients, including non-diabetics, focusing on average glucose and variability rather than spikes. He is optimistic about the Aktiia continuous blood pressure bracelet, available in Europe but awaiting FDA action, and wishes for continuous lactate monitoring.
- •CGM helps clarify cases in the middle between clearly healthy and diabetic by OGTT
- •Average blood glucose and standard deviation matter most; spikes matter least
- •His highest CGM reading was about 180 after a vegan restaurant dessert
- •The Aktiia bracelet gives readings every two hours and works about as well as an automated cuff
- •He would love continuous lactate monitoring during Zone 2 and VO2 max workouts
