305 ‒ Heart rate variability: measure, interpret, & utilize HRV for training and health optimization

1. 0:00 – 1:53

   Intro

   1. JJJoel Jamieson0:00

      I, I think what it comes down to is each person has a certain amount of training in a week they're gonna... I like, I think it's a weekly basis, right? 'Cause that's kind of the cycle we live in. There's an amount and a type and an intensity of training that you are individually going to respond the best to, and if you go above it, not so great things are gonna happen. If you go below it, you're, you're not gonna get the outputs you want. And that amount is not easy to find, and it changes on a weekly basis. It's not the same-

   2. PAPeter Attia0:25

      Right

   3. JJJoel Jamieson0:25

      ... week in, week out. And so the more that you can hone in on that core, how much volume do I need and how much intensity do I need? If you can get that right week in and week out, you will see continual improvements, and that work will turn into result. If you don't answer that correctly, bad things happen. You either waste your time because you're not getting as much out of it as you could, or you do end up over-trained, in which case we see injuries, and we see burnout and lots of things that are gonna have negative health consequences. So I think ultimately what you said is, "I wanna use information to make sure that I am getting the most bang for my buck, the best result for the amount of work I'm putting in." And that's where I think data can play a really powerful role, is it's information that you can use to make much more granular decisions around, rather than just guessing, "Oh, I should go do 40 minutes today." Should you? Or, "I should do 200 minutes this week." Is there anything to support that-

   4. PAPeter Attia1:16

      Yeah

   5. JJJoel Jamieson1:16

      ... other than just throwing stuff at the wall and seeing what sticks? And I think that's what intrigued me so much about HRV, is it felt like I could open the black box and get some real answers other than, like, test, train for eight weeks, remeasure, see what happened.

   6. PAPeter Attia1:29

      Yeah.

   7. JJJoel Jamieson1:29

      I don't wanna wait eight weeks. I don't wanna potentially lose the gains I could have made across that time period. So for someone like yourself, that's, again, wanting to get as much out of their time as they possibly can, yeah, data can play a really strong role in that 'cause it can answer questions that can't be answered otherwise.

   8. PAPeter Attia1:42

      [upbeat music] Hey, everyone, welcome to "The Drive" podcast. I'm your host, Peter Attia.

2. 1:53 – 10:11

   Heart rate variability (HRV): evolution, science, and practical applications of HRV in athletic training

   1. PAPeter Attia1:53

      Hey, Joel, thanks for coming out to, uh, to Austin. Um, and, uh, you know, been, uh, looking forward to this discussion for some time. We've not met before but had, uh, what seems like an endless stream of email communication, so I always appreciate your, uh, your willingness to not just respond to all my questions, but the thoroughness with which you do so. Um, this is a topic that, as we were discussing just a few minutes ago, I think, uh, everybody has heard of it. People have a vague sense of what it is.

   2. JJJoel Jamieson2:23

      Mm-hmm.

   3. PAPeter Attia2:23

      But once you get beyond a very superficial description of it, most people, um, I think don't really understand it, and certainly most people don't understand how to use the data, and I would absolutely include myself in that category. So the topic, of course, um, of, of heart rate variability is near and dear to your heart. Um, maybe before we dive into the weeds of this stuff, maybe just give folks a bit of a sense of your background-

   4. JJJoel Jamieson2:51

      Sure

   5. PAPeter Attia2:51

      ... and, and kind of what brought you to, to the study of this and, and, you know, over what period of time.

   6. JJJoel Jamieson2:58

      Yeah, I mean, look, it's, it's really interesting to me to see the growth of it because I've been using it now for 20 years, and the story of it's, it's really fascinating to me because I was in my early 20s, and I had just graduated from University of Washington. Um, I'd interned there and done some strength and conditioning, and then was progressing to the Seahawks to work with the same coaches. And there was a track coach named Randy Huntington, and most people probably never heard of Randy, but he was the USA track and field jumps coach. He coached Mike Powell, who broke Carl Lewis' long jump world record-

   7. PAPeter Attia3:25

      In 1993, right?

   8. JJJoel Jamieson3:27

      Something like that, yeah.

   9. PAPeter Attia3:27

      Yeah, I remember that.

   10. JJJoel Jamieson3:28

       So Randy, Randy was around for a long time. He was a tremendous coach, and he was from my area. And I just kind of was talking to him one day, and I asked him some general advice. You know, as a young coach, what would you suggest and, you know, resources and all this sorts of stuff. And he writes a phone number down for me and says, "You need to call this guy." [chuckles] And I was kind of like, "Okay," you know, "Uh, uh, whatever you say, Randy." And so I call this guy, and this, this thick Russian accent answers the phone and says his name is Val, and I still don't really know what I'm calling this guy for. I just know that Randy told me to. And so he says, "I'll be in your area. I'll meet you at the airport." And I still-- I'm like, [chuckles] "Okay," right? Like I- I'm just kind of playing along, and I'm not really sure what the, the whole point of this is, but Randy says, "Call this guy," so I call this guy, and he just says, "I, I will show you the technology." And I'm, again, kind of like, [chuckles] "Okay." Uh, and so I go down to the SeaTac Airport, and I see this kind of big Russian-looking guy with a trench coat. I mean, it looks like it could be straight out of a movie. And he, like, introduced himself, and he's like, "Lay down on the couch." And so-

   11. PAPeter Attia4:27

       I hope you're now out of the airport or-

   12. JJJoel Jamieson4:29

       No, I'm in the, well, I'm in the hotel by the airport-

   13. PAPeter Attia4:31

       Okay, all right

   14. JJJoel Jamieson4:31

       ... actually, yeah. So, you know. And, and so again, I'm kind of-- I'm just in the dark on what is going on, and he says, "Lay down on the couch." And so I lay down on the couch, and he's like, "Take your shirt off." [chuckles] And I'm, I'm-- at this point, I'm looking around like, is there some kind of practical joke? Like, is, is Randy just messing with me?

   15. PAPeter Attia4:46

       This is when you have a lot of faith in Randy.

   16. JJJoel Jamieson4:47

       This is when I have a lot of faith in Randy, and it paid off. Um, and so he does this big briefcase, and he pulls out this big laptop, and he starts plugging in wires and all this sort of stuff, and he pulls out these electrodes. He starts putting them on my chest, and he does basically an ECG. And he's asking me birth date and weight and all this sort of stuff, and he's like, "Don't move." And so I sit there for two and a half, three minutes, and I see all this stuff on the computer happening, and I'm, again, still just completely in the dark, right? What, what, what is this guy doing to me? Like, I have no idea. Um, and after about three minutes, he's like, "Finished. You know, sit up." And he starts kind of telling me about my recovery status and my readiness, my metabolic profile, my central nervous system. Starts telling me about all this stuff that didn't really make a whole lot of sense of how he would know. And he was, he was like, "You know, you're much more strength-oriented, and your cardiovascular system's not very good," which is accurate at the time. Maybe didn't take a computer to see that 'cause I was definitely on the strength side. But he started just telling me this story of HRV and heart rate variability, and this was, again, 20-plus years ago, where it was not something that people were aware of, and I had never, of course, heard of it. And the idea that you could take something out of a laptop, connect it to my body, and have any idea of physiologically what I was as an athlete or as a human being was completely new and seemed foreign to me, and I immediately was like, "I need this." Because it seemed to me like there's so much of a black box when it comes to fitness, right? Like, sometimes I do a workout and I get better. Sometimes I do workouts and I don't. Why? Like, what is, what is the right magic answer here to always get the workouts that I wanna see, or the results? And so he started talking about the story of heart rate variability, and this is really fascinating because you don't read this when you look at the Western literature. So, you know, as you, you probably know, it goes back way, 1700s. They were aware of beat-to-beat intervals. Chinese have used pulse medicine a long time. But the Russians were pretty ahead of the game as far as application of HRV. So in the 19-- late 1950s, they were aware that from an ECG you could pull out these beat-to-beat intervals and get something more than just heart rate. And so when they would send the first human being to space, Yuri Gagarin, they were able to send back the ECG and some respiratory data and see fundamentally what happened to people when you shot them into space, which they really didn't have a way of gauging without this. And so they saw as soon as he went into space, his HRV went way up, probably because you have changes in blood pressure, you have less gravity, so you don't have to have as much muscle activity. And they started using this-

   17. PAPeter Attia7:14

       Hmm

   18. JJJoel Jamieson7:14

       ... literally all the way back in the 1960s, which is pretty fascinating, 'cause you didn't really see that in the Western literature for decades later, really, in a meaningful way. Then in the 1980s, they were dominant as far as all the Olympic sports, right? They just crushed us. Now, they had a very elaborate drug program. They had a very elaborate training program. They had, you know, a lot of different things that gave them the advantage. But in the mid-1980s, they started basically figuring out, can we use this tech for sport performance? And so they m- uh, put together an engineering team, um, and they started collecting data on thousands of Russian athletes of all levels, from their school-age kids all the way up to their Olympic athletes, and they collected just populational norms. And they started building this system that was meant to monitor training and, you know, be used for this purpose. And they-- you know, don't get me wrong, they had really high volumes, but they did blood monitoring, like, weekly or monthly. They were constantly testing. They-- you know, from an organizational standpoint, their communist structure gave them a very hierarchical way to organize this sort of stuff and monitor it. So anyway, they spent years working on this platform, and then before they could finish it, the Soviet Union collapsed, and kinda the whole team that was involved in this just dispersed and left, left Russia. And just by chance, a lot of them had been involved in track and field and different sports. They end up reconvening at a track meet in Eugene and kinda just talking about this path project, and they decide that they wanna get together and keep working on this, 'cause they never brought it to fruition. And they did, and that was ultimately the first system that I think was available. I mean, it was the first system-

   19. PAPeter Attia8:45

       Hmm

   20. JJJoel Jamieson8:46

       ... that was available commercially with, with the intent of being used for sport and fitness, and that was what I was being introduced to at the time. Um, this was, this was the result of this project being finished. Uh, the problem is they wanted $35,000 for it, and it was, you know, it was a very research-heavy, medical-type system that was not easy to interpret. And I didn't have $35,000, um, but I convinced them to let me help them introduce it to teams across the US and gain some exposure for them, and so we worked out a deal, and I started using it. But it gave you 12 or 14 different metrics of heart rate variability. It required you, like I said, connect electrodes to people before you'd measure them, and really was that introduction to it where I started this whole journey. And, you know, 20 years of looking at data and coaching people and trying to understand what the data was telling me and how it aligned with all these other metrics has really just led me down this path of, of how you get to heart rate variability today. And it's, you know, it's certainly been a large change, but it's kind of that, that crazy journey of starting one day on a laptop in a, you know, in a hotel next to the airport, and now it's on everyone's phones and watches and everything else. But I spent, like I said, 20 years coaching with it, and that's really the, the difference is I was a coach. I opened a gym. I worked with lots of fighters and athletes and different teams and military groups using data, looking at HRV, you know, the whole, the whole nine yards. So it's, uh, it's been a long time, but it's, it's really fascinating to see it grow.

   21. PAPeter Attia10:10

       So

3. 10:11 – 21:45

   Methods of measuring HRV: EKG, wrist-based sensors, and more

   1. PAPeter Attia10:11

      let's talk a little bit about the, the actual measurement.

   2. JJJoel Jamieson10:14

      Okay.

   3. PAPeter Attia10:14

      Um, so in, in the example you gave when you were first introduced to it, it was done off an EKG. Um, I, I assume three leads would be sufficient.

   4. JJJoel Jamieson10:24

      It was six back then.

   5. PAPeter Attia10:25

      Okay.

   6. JJJoel Jamieson10:26

      But you can certainly get it from three, obviously.

   7. PAPeter Attia10:27

      Yeah. So would we say, Joel, that that's still the gold standard for how to measure HRV?

   8. JJJoel Jamieson10:33

      Yeah, absolutely. I mean, if you're talking about medical-grade research quality, you want the cleanest signals, you want the most signals, ECG, three-lead, six-lead is, is by far the way to go.

   9. PAPeter Attia10:43

      This might be a little too in the weeds, but given how technical this topic is, do you want to explain how an EKG works? Because I think it will be relevant to distinguish between what an EKG is doing-

   10. JJJoel Jamieson10:56

       Sure

   11. PAPeter Attia10:56

       ... what a chest strap is doing, what an optical sensor is doing on the forearm, on the wrist, or on the finger. These are all going to be basically the tools the technology companies are using to measure HRV. But as you and I have discussed and, you know, gone deep on this, uh, there's a total difference in the fidelity of the signal depending on where the signal is acquired.

   12. JJJoel Jamieson11:19

       Yeah, exactly.

   13. PAPeter Attia11:19

       And, and, and given that our audience here is, uh, an appreciative audience for nuance, I, I think it might be worth explaining from the gold standard all the way down how these signals are acquired, what's happening physiologically and electrochemically that's enabling the capture of the signal.

   14. JJJoel Jamieson11:35

       Sure. I mean, you can kinda group these into two things, right? One is the electrical signal of the heart itself, right? And that's what we're measuring with an ECG or EKG, uh, or the chest strap. You're literally measuring the polarization, repolarization of the heart as the chambers are beating, and you get this electrical signal that gives you the QRS complex, right? And we're honing in on where those beat-to-beat intervals are, because ultimately to get HRV, we need the exact amount of time from one heartbeat to the next, because that's what we're quantifying. So if you have electrical signal, you get a very clear clean signal that you can pull out those exact beat-to-beat intervals, and that's where we fundamentally get heart rate variability from. If we're talking the-

   15. PAPeter Attia12:15

       And is it alwa- I mean, is it always done R-to-R? 'Cause that's-

   16. JJJoel Jamieson12:18

       Yes

   17. PAPeter Attia12:18

       ... the cleanest signal.

   18. JJJoel Jamieson12:19

       Yeah, it's always done R-to-R.

   19. PAPeter Attia12:20

       Yeah.

   20. JJJoel Jamieson12:20

       So you just have to be able to identify where is the peak of the R interval, right?

   21. PAPeter Attia12:23

       Yeah.

   22. JJJoel Jamieson12:23

       The more accurate that you can identify here's the peak of the R wave, here's the peak of the R wave, the more accurate you can get that-

   23. PAPeter Attia12:28

       And if my memory serves me correctly, 'cause it's been so long, right? So the P is the polarization of the atria, uh, and then the QRS is the ventricular... Is it the repolarization or the contraction?

   24. JJJoel Jamieson12:41

       I believe it's the repol- I believe it's the contraction.

   25. PAPeter Attia12:43

       Yeah, and then the T wave is the repolarization.

   26. JJJoel Jamieson12:45

       Exactly.

   27. PAPeter Attia12:45

       So you're basically, the R wave is giving you, if my memory serves me correctly, I'm sure there's a cardiologist listening who's gonna scream right now, but that's the peak electrical signal of the contraction of the ventricle.

   28. JJJoel Jamieson12:56

       Exactly.

   29. PAPeter Attia12:56

       Okay.

   30. JJJoel Jamieson12:56

       Yeah, I'm not a cardiologist either, but from my mo- my, my memory, that's correct as well.
4. 21:45 – 25:10

   How HRV is calculated from the data

   1. PAPeter Attia21:45

      okay, let's now talk about the very confusing subject of how one calculates heart rate variability because let's, again, reiterate what we're talking about, right? So if anybody has seen an EKG, everybody watching us has, you've got your little P, Q, R, S, T, and you just line up a strip of those, and you... Imagine you were doing this in the olden days. You'd have a set of calipers.

   2. JJJoel Jamieson22:13

      Mm-hmm.

   3. PAPeter Attia22:13

      You'd literally measure across R to R to R to R. So let's pretend we have a minute's worth of data, Joel.

   4. JJJoel Jamieson22:20

      Mm-hmm.

   5. PAPeter Attia22:20

      And a person's heart rate is they're, they're laying down and resting, so they're at 60 beats per minute. So the approximate beat-to-beat interval is one second-

   6. JJJoel Jamieson22:32

      On average

   7. PAPeter Attia22:32

      ... or, sure, yeah, on average, or 1,000 milliseconds. Um, what's happening at the physiologic level that makes it such that there is variation, and how is that measured and calculated from the raw data? And let's start with the gold standard and assume you have an EKG.

   8. JJJoel Jamieson22:53

      Sure. Yeah, as you mentioned, you're starting with this gold standard of, okay, we can accurately pinpoint where are these R-to-R intervals, and so we pull out what are called the RR intervals, not, you know, surprisingly, and we'll plot those. Now, from there you do what's called correction basically. You have to filter data there for filter ectopic beats, which are beats that don't actually arise in the sinoatrial node. You fill out if there is any noise in the signal or anything like that, and you end up with this clean set of RR intervals.

   9. PAPeter Attia23:21

      And let's, so let's say I gave you 60 of them.

   10. JJJoel Jamieson23:23

       Sure.

   11. PAPeter Attia23:23

       And it's, again, it's a person who's at rest, so, um, on average it's 1,000 milliseconds between them, but I'm gonna give you 60 numbers that vary from 900 to 1,100 milliseconds.

   12. JJJoel Jamieson23:36

       Exactly.

   13. PAPeter Attia23:37

       Okay.

   14. JJJoel Jamieson23:37

       Yep. So this is where things get interesting because when we talk about HRV, we just usually give a number.

   15. PAPeter Attia23:43

       Yeah.

   16. JJJoel Jamieson23:43

       And that number can be different. But a better way to think about HRV is just a framework to assess variability because there are multiple ways to calculate that. There's one category called time domain where we literally just do some math. The most common one is RMSSD, root mean success- successive squared differences, where they just do some basic math, and they get that number of milliseconds of RMSSD. There's SDNN. There's PNN50. There's all these different call 'em time domain where they just are taking that time series, doing some math on it, and giving you a number that represents the average variability. Now-

   17. PAPeter Attia24:17

       So let's talk about the RMSSD-

   18. JJJoel Jamieson24:19

       Sure

   19. PAPeter Attia24:19

       ... because it appears to be the most common one.

   20. JJJoel Jamieson24:20

       It is most common for multiple reasons.

   21. PAPeter Attia24:22

       Yeah.

   22. JJJoel Jamieson24:22

       What we are, again, measuring is that average variability across that time span, and what that represents is the input of the vagus nerve, the parasympathetic system, and its input into that sinoatrial node of the heart because fundamentally the autonomic nervous system is, is governing that heart rhythm, and primarily what happens at rest Is it's that parasympathetic system via the vagus nerve. And the way that it works is it's innervating that sinoatrial node in the heart, and it's pulsing in beat with respiratory processes. So as we inhale, that vagus is inhibited, and you get kind of this acceleration of heart rate. Now, actually, I should back up. If you were to cut out the autonomic nervous system, you'd have roughly an intrinsic heart rate of about 100 beats per minute, somewhere in that range. Everybody basically does. So if you just-

   23. PAPeter Attia25:09

       And, and

5. 25:10 – 33:14

   The role of the autonomic nervous system (ANS) in regulating HRV

   1. PAPeter Attia25:10

      just let, let, let's be back up even a little further, Joel.

   2. JJJoel Jamieson25:12

      Sure.

   3. PAPeter Attia25:12

      I think there's a lot you and I would take for granted here. Um, so sort of nervous system 101, we have two nervous systems, broadly speaking. We have one that's under our control-

   4. JJJoel Jamieson25:22

      Yep

   5. PAPeter Attia25:23

      ... and one that is not. So most of what you and I are doing that people can watch, the movement, speaking, all of these things, that's voluntarily under our control. But what most people can't see when they're looking at themselves is how many things are happening without any input. And thank God for that system. That system happens to be called the autonomic nervous system. Without it, we would forget to breathe, and we would die.

   6. JJJoel Jamieson25:48

      Yeah, we don't think how many times the heart should beat. Yeah.

   7. PAPeter Attia25:51

      Our heart would stop beating. Like, so all of these vital functions from respiration to heart beating to regulating blood pressure to digesting have to happen via a nervous system that we never think about.

   8. JJJoel Jamieson26:02

      Yep.

   9. PAPeter Attia26:03

      That system's further subdivided into the two terms you've already brought up, a sympathetic system and a parasympathetic system, and you've already alluded to one of the most important nerves in that parasympathetic system called the vagus nerve, which is a cranial nerve, so originates from a very primal part of the brain.

   10. JJJoel Jamieson26:21

       Yep.

   11. PAPeter Attia26:22

       And we won't necessarily get into all the neurotransmitters involved in these things, but what you're basically describing is that the heart is under the influence of both of these.

   12. JJJoel Jamieson26:33

       Exactly.

   13. PAPeter Attia26:33

       An example th- to-- gets to your point is after a patient has undergone a heart transplant for, a- as an extreme example, that vagus nerve is transected. Their heart is no longer under that control.

   14. JJJoel Jamieson26:47

       Nope.

   15. PAPeter Attia26:47

       And therefore, it's just going to have kind of-

   16. JJJoel Jamieson26:49

       And you would see heart rate variability of basically zero-

   17. PAPeter Attia26:51

       Yeah

   18. JJJoel Jamieson26:52

       ... in that scenario.

   19. PAPeter Attia26:52

       Yeah.

   20. JJJoel Jamieson26:52

       Because it would just beat like a metronome.

   21. PAPeter Attia26:54

       Yep. Um, okay, so didn't mean to interrupt-

   22. JJJoel Jamieson26:56

       Yeah, yeah

   23. PAPeter Attia26:56

       ... but I think that might be just helpful context for people-

   24. JJJoel Jamieson26:59

       Yeah, I think that's-

   25. PAPeter Attia26:59

       ... to sort of understand what we're talking about, which is you're talking about even though that person's heart is beating at 60 beats per minute, there's still a very fine interplay-

   26. JJJoel Jamieson27:08

       Yes

   27. PAPeter Attia27:08

       ... between what the sympathetic nervous system is doing and what the parasympathetic nervous system is doing.

   28. JJJoel Jamieson27:14

       Yeah, and we should probably even back up a little bit more that the whole reason that we need this autonomic nervous system is to keep us physiologically within these normal ranges that we have to be in to be able to produce energy and stay alive, right? So if our blood pressure goes too high or too low, if our blood glucose gets too high or too low, if our body temperature gets... All of these things have to be within physiological norms, and we'd call that homeostasis, that the internal environment has to be controlled at all times, regardless of the external environment, right? So whatever temperatures we're in, whatever we're eating, whatever we're doing, we have to be able to regulate internally and stay within these physiological norms that are necessary for survival. And that fundamentally is what the autonomic nervous system is doing. It's keeping us alive, and it's trying to match the internal demands with whatever we're trying to do, given the external environment, right? So like you said, people have heard of probably these two branches, the sympathetic, the fight or flight, or the parasympathetic, which people call rest and digest. Now, that's a good terminology to understand, but it makes us only think of the sympathetic-

   29. PAPeter Attia28:16

       Yeah, it's, it's not nuanced enough

   30. JJJoel Jamieson28:17

       ... it's, it's not nuanced enough. It also makes us think the sympathetic isn't doing anything unless we're fighting or running.
6. 33:14 – 37:00

   The decline in HRV with age, and the mitigating effects of fitness and other lifestyle factors

   1. PAPeter Attia33:14

      things that I remember from, uh, an AMA that I did on heart rate variability a couple of years ago, and we'll link to it here in the show notes so that people can go back if they want a real primer on HRV. Um, the reason we did, uh, a, a, a sort of an AMA on that was, you know, a lot of people had questions about it. I don't-- frankly, I don't think we went into nearly, um, this level of detail about it. We talked much more about the mortality data and things of that nature. But that was one of the first things that stood out, right? Two, two things I remember more than anything, Joel. The first is, um, there was a relationship between, in the research literature, what was measured as HRV, and we should talk about what that means, and, uh, all-cause mortality and even disease-specific mortality. And the second thing that really stands out is a graph that I'll never forget that shows on the x-axis age, on the y-axis HRV, and what the curve looked like, and I couldn't believe-

   2. JJJoel Jamieson34:10

      Mm-hmm

   3. PAPeter Attia34:10

      ... how steeply it declined, right? So the, the, you know, the-- you-- and I think what it was plotting, if I'm not mistaken, was kind of mean or median HRV with, uh, you know-

   4. JJJoel Jamieson34:20

      The band

   5. PAPeter Attia34:20

      ... with a band of-

   6. JJJoel Jamieson34:21

      Yeah

   7. PAPeter Attia34:21

      ... you know, w- you know, plus or, you know, call it the in-- 80% or interquartile range or something like that. But it was an unmistakable trend, right? Which is, like, a 50-year-old's HRV is less than half of a 15-year-old's. Um, and it just keeps getting further and further crushed as we go down. I suppose that speaks to what you said earlier, right? Which is one of the hallmarks of aging is this sort of lack of resilience.

   8. JJJoel Jamieson34:45

      Yeah, exactly.

   9. PAPeter Attia34:45

      And we see it on every level.

   10. JJJoel Jamieson34:47

       Mm-hmm.

   11. PAPeter Attia34:47

       But this is just, uh, a very notable example, which is even at the level of the autonomic nervous system, we lose the ability to recover from insult. And life is an insult.

   12. JJJoel Jamieson35:00

       Exactly. Exactly.

   13. PAPeter Attia35:01

       Everything in life is an insult.

   14. JJJoel Jamieson35:02

       In, in the world around us is insult, insult time.

   15. PAPeter Attia35:04

       Yeah.

   16. JJJoel Jamieson35:04

       It's just we can respond much better to it as we're younger.

   17. PAPeter Attia35:07

       Yeah. Do you have a sense, by the way, of what it is physiologically at the cellular level that is resulting in this profound reduction in HRV as we age?

   18. JJJoel Jamieson35:18

       You know, it's interesting. They've, they've looked at this, and I don't know that we have a great answer for the exact physiological mechanism. We know it's tied to, to mitochondrial density, mitochondrial function. We know it's tied to elements of the immune system. We know it's tied to hormonal status, and we obviously see decreases in all those things as we age. So there's probably-

   19. PAPeter Attia35:34

       You just have to wonder which ones are causal-

   20. JJJoel Jamieson35:36

       Yeah. I don't, I don't know

   21. PAPeter Attia35:36

       ... and which ones are the response.

   22. JJJoel Jamieson35:38

       I don't think we-- I don't, but I don't think we know that, but we definitely know that we can increase our HRV, or we can at least pr-prevent the decline most effectively through cardiovascular fitness. We see people with higher VO2s-

   23. PAPeter Attia35:48

       Yeah

   24. JJJoel Jamieson35:48

       ... have higher mitochondrial function. They have higher VO2 that leads to, or at least correlates with greater HRV. So we know that cardiovascular fitness in general seems to be the most closely tied to average HRV. And there's, there's also a pretty strong genetic component, which we can't ignore, um, and we can talk about that. But yeah, if you look at the hallmarks of aging paper, which I'm sure you've seen, they kind of take these buckets of things, right? They say, "Oh, as you age, you get dysbiosis, you get the deregulated nutrient sensing, you get senescent cells, you get stem cell exhaustion, you get mitochondrial..." They, they list all these things that happen as we age, and they kind of look at this prism of what's the output. And if you read that, they say, okay, the output, two of the major things are loss of resilience to homeostasis and lack of a stress response that's appropriate given the world around us. So yeah, where that cause and effect and which one's, you know, causing the other is, is tricky to say. But I think fundamentally, aging is this progressive loss of adaptability, and there's multiple pieces to that, obviously. But we're measuring that, as you mentioned, is, you know, one of the things that we want to gauge of HRV is how much of that resilience, of that adaptability are we losing as we age, and that's something we can influence through lifestyle and training and everything else that we're trying to do here to, to prevent that slowdown.

   25. PAPeter Attia36:59

       One of the things

7. 37:00 – 43:58

   The role of genetics in HRV, the modifiability of HRV, and a comparison of VO2 max and HRV as predictors of mortality

   1. PAPeter Attia37:00

      in that AMA that I didn't get a great answer to was how much genetics played a role on this. But from our patient population, because even though that's a, not a huge N, it's -- we've got years and years of seeing these data in patients where every single one of them is using some sort of device. And it, it, by the way, it's even devices we haven't talked about. Like, if you look at, you know, really high-end things like, you know, uh, uh, like mattress covers and things like that, like the Eight Sleep-

   2. JJJoel Jamieson37:32

      Yeah

   3. PAPeter Attia37:32

      ... will now measure that quite accurately. Um, so e- from every form of wearable and, and out, you, you've, you've got endless streams of data, and there's an unmistakable difference between people. I mean-

   4. JJJoel Jamieson37:45

      There is

   5. PAPeter Attia37:45

      ... there are some people who... And let's just talk about this in RMSSD. We should talk about the other-

   6. JJJoel Jamieson37:51

      Sure

   7. PAPeter Attia37:51

      ... numbers 'cause they, you k- you have to do this apples to apples.

   8. JJJoel Jamieson37:54

      Yep.

   9. PAPeter Attia37:54

      But if we just talk RMSSD, you know, I've got patients who live at 100, and a good day for them, a good day for them, quote, unquote, they're at 120, and a bad day for them, they're at, you know, 85. But, you know, if you follow them for five years, their average HRV is gonna be 100 milliseconds. I've got other patients whose average HRV is 15 milliseconds, and a good day for them is 25 to 30, and a bad day for them is 10. Um, h- how could that be explained by something other than genes?

   10. JJJoel Jamieson38:29

       It, it isn't. I mean, there's... I've looked at a bunch of this research just to understand the, the... And it's all over the map depending on what paper you're looking at, depending on which metrics they calculated. They, they say genetics is somewhere between, like, 15 and 70-something percent of HRV.

   11. PAPeter Attia38:41

       Yeah.

   12. JJJoel Jamieson38:41

       There's just such a wide range in the research of what you see.

   13. PAPeter Attia38:44

       Mm-hmm.

   14. JJJoel Jamieson38:44

       You know, where that exact number falls, I'm not sure. But you definitely see a very strong genetic component to it. Why? I don't think we truly understand that. But as you mentioned, I see people who don't work out at all, and they come into the gym or they, you know, whatever, and you look at their numbers and you're like, "You have a very high HRV that you would not expect 'cause you clearly don't have a very high level of cardiovascular fitness." But I'll say kind of as a whole, if you start talking to those people, they tend to have a healthier family history. They tend to have better health markers. I think there's something to that, in that that higher HRV probably still correlates to a health benefit, even if it doesn't necessarily come from exercise-derived means. It's just a genetic thing that they have that probably confers some benefit.

   15. PAPeter Attia39:23

       Would you put HRV in a comparable bucket to VO2 max in terms of the following: uh, comp- you know, me- amount of it that is genetically determined, amount of it that is modifiable, and the, the, the role it might play in understanding overall health status? So for VO2 max, I know the answers to all those questions, right? It, there, there is a genetic component. It's not huge. It's probably closer to that 15% than 70%. Uh, it's highly modifiable but difficult.

   16. JJJoel Jamieson39:59

       Yep.

   17. PAPeter Attia39:59

       And the fact that it's highly modifiable but difficult to modify is why I believe it is, you know, and you've probably heard me say this, the single greatest predictor we have of mortality. Um, and if there's a better one out there, I'd like to hear it, but I haven't seen one. And I think that's because it, I always talk about VO2 max as, like, the integrator of so much hard work.

   18. JJJoel Jamieson40:21

       Yep.

   19. PAPeter Attia40:21

       Like-

   20. JJJoel Jamieson40:21

       It's li- it's, you can't get there unless you-

   21. PAPeter Attia40:22

       Yeah, you can't, you can't cram for the test

   22. JJJoel Jamieson40:24

       ... e- e- exactly.

   23. PAPeter Attia40:24

       If, if, if your VO2 max is in the top 1%, you weren't born there. You, you, you blood, sweat, and tears your way to that, and all that work does so much good for you.

   24. JJJoel Jamieson40:37

       Yep.

   25. PAPeter Attia40:37

       Okay, so let's use that framework to evaluate HRV. S- you know, how genetic is it? Um, how modifiable is it? And are the, do the modifications you have to put into it then speak to, hey, if somebody improves their HRV by 50%, how confident are we that that moves the needle in terms of what actually matters, which is not the silly number, but actually the outcome of their life?

   26. JJJoel Jamieson41:02

       Sure. No, I think it's more genetically based just from what I've seen, and probably a bit less modifiable. I would say it's less predictive in the sense that if I have somebody who's got an H- or, you know, an HRV of, you know, 110, to use your example or whatever, and then I have someone who's got a VO2 max that I know is, I don't know, 70, I can pretty well know that person with a, a VO2 max of 70 [chuckles] is pretty aerobically fit, and they've lived a pretty solid lifestyle and had to have done the, the work and the training to, to get that level. I'm more confident in that that person's longevity will be benefited and, and affected from that, than I'm confident in somebody who has no-

   27. PAPeter Attia41:35

       Mm-hmm

   28. JJJoel Jamieson41:35

       ... workout history that just has a high HRV. I don't know that I can say with the same confidence at all that just because they have a higher HRV that they would have the same prognes- prognostic value in all-cause mortality. So it's, it's a, it's a metric that we aren't gauging output from, right?

   29. PAPeter Attia41:51

       Yep.

   30. JJJoel Jamieson41:51

       We're just measuring this internal physiological state, and I think that confers benefits to someone who has higher HRV. But I can't necessarily just looking at that number instantly say, "Oh, this person's really healthy," or, "This person's really fit," necessarily.
8. 43:58 – 50:43

   How aging affects HRV and sympathetic drive, and the importance of spontaneous movement and exercise in maintaining the body's adaptability

   1. PAPeter Attia43:58

      do you have kids?

   2. JJJoel Jamieson43:59

      I don't.

   3. PAPeter Attia43:59

      So, um, anybody who's got kids, especially young kids, will appreciate this comment. But, um, I've become so much more cognizant of a, um, a metric I would love to introduce to the world, uh, that ties into what you're describing called spontaneous movement, right? So I'm an old guy, and even though I'm fit for my age, like, I don't waste a lot of movement, right? So I'm already at that stage in my life where I just actually think of myself as quite lazy, right? So I love to exercise, and obviously I'm not lazy when I'm doing that. But, like, if I'm walking through the airport, I'm just walking. I will use the stairs and not the escalator and all that stuff. I get it all. But, like, if you're with my kids, and my two boys are six and nine, the amount of spontaneous-

   4. JJJoel Jamieson44:51

      Mm-hmm

   5. PAPeter Attia44:51

      ... explosive movement is something I don't remember doing as a kid, although I'm sure I did it too. But it's really a remarkable thing. And we also have a puppy. So we have this puppy that also is bouncing off walls. But when you see older dogs, that's done, right? Like, the, a 14-year-old dog is not-- even if it's in good health for its age, it's not bouncing off the walls, whereas that puppy can't stop moving. And, and the same thing, like, when I look at my boys, like, everywhere we go, they have to race. Everything is a race.

   6. JJJoel Jamieson45:25

      [laughs]

   7. PAPeter Attia45:26

      They're g- they're sprinting there and back. So if we're walking somewhere, they're doing sprints to and from us the whole time. And I, I just think, A, there's something beautiful about that, and it, uh, but I think it speaks to this idea of youth, right? Youth is about movement.

   8. JJJoel Jamieson45:42

      Yep.

   9. PAPeter Attia45:43

      It is converting the chemical energy of our food into the electrical energy that powers muscles. And spontaneous locomotion seems to be this. So I don't know. At some point, like, I would love to know, like, is there a way to take that as another output metric, which is-

   10. JJJoel Jamieson45:59

       Put a GPS on somebody-

   11. PAPeter Attia46:00

       Yeah, exactly. Like-

   12. JJJoel Jamieson46:00

       And see what they're doing

   13. PAPeter Attia46:01

       ... what is the drive to spontaneously-

   14. JJJoel Jamieson46:03

       Yeah

   15. PAPeter Attia46:03

       ... move for no apparent good reason?

   16. JJJoel Jamieson46:04

       You know, the thing we talk about we lose HRV, right? But we also lose sympathetic drive, too.

   17. PAPeter Attia46:08

       Mm-hmm.

   18. JJJoel Jamieson46:08

       We lose some of that ability to turn that sympathetic dial up as we get older, too. And probably it's as we've lost both of those capabilities, the ability to turn that sympathetic dial up and crank out more energy and produce adrenaline, uh, and cortisol.

   19. PAPeter Attia46:20

       Is that what you think explains the fall in maximum heart rate? Is it just purely a loss of-

   20. JJJoel Jamieson46:24

       Yeah, it's part of it. It's lack of, a loss co- loss of contractility of the heart, loss of contractility of the muscular system, loss of hormonal release as a result of the sympathetics. I mean, you're just losing, again, this adaptability, this, this ability to turn those two dials as necessary to meet whatever demand you're placing on the body. If we can't turn that sympathetic dial up as much, we don't have that spontaneous energy that you just described to get up and sprint 'cause that s- that dial is way slower, and it probably can't go up as high.

   21. PAPeter Attia46:51

       Yeah, so it's like we're born with a zero to 10 rheostat or dial on both of them.

   22. JJJoel Jamieson46:56

       Yep.

   23. PAPeter Attia46:56

       And as you age, that 10 goes to a nine, eight, seven, six, five, and-

   24. JJJoel Jamieson47:01

       Yeah, you lose that

   25. PAPeter Attia47:02

       ... you can still move them, but you just can't move them as much.

   26. JJJoel Jamieson47:04

       Yeah, 100%. That's, I would call, like, autonomic range. And, and that really kind of represents what is our body capable of from an energetic standpoint. How quickly can we turn that dial up? And then conversely, how quickly can we turn that dial back down and crank up that parasympathetic side to restore homeostasis and get our bodies back to normal? And it's, it was interesting if you look at, um... I've looked at a paper where they looked at different, uh, Navy divers that were going through this qualification school, which is kind of their equivalent of, of, uh, SEAL training and, you know, Hell Week and all that. And they tried to pick out what are the variables that separate the people that are really good at this and succeed and make it through versus the ones that don't, and they measured HRV throughout the process. And essentially, they find what I just talked about, is this autonomic range where they could really crank up the sympathetic system when they needed to and then turn it off as soon as that stressor is over and respond in the other direction with a much higher parasympathetic response. That ability to use those dials quickly and in the right combination seems to be a really key thing to, again, adaptability. And as we said, if you age, if both of those dials lose their range and they lose their coordination to some respect, then we have much less resilience, much less adaptability. And we should mention, too, as you pointed out, the vagus and the sympathetics, they do influence behavior in a lot of ways. There's a, there's a whole thing that's beyond, outside my lane in the psychosocial aspect of this, and you can look up the polyvagal theory by Stephen Porges. Um, but fundamentally, the brain regulates emotion through autonomic function in some capacity, and the vagus is related to social behaviors. It's related to, uh, cognitive control in, in different scenarios. It's related to all sorts of stuff. They, they call it fight, flight, freeze, you know, all these things related to how our autonomic nervous system is influencing our emotions. And if we don't have that autonomic range, we probably have less drive to get up and move around as a result of that, as those, those nerves in the autonomic system changes what it can, can and can't do.

   27. PAPeter Attia48:55

       I mean, I, I don't think that should ever be underestimated or, or understated. I think, again, just even looking at a sample size as small as our patient population, I think we see that a lot. I think there's a very clear association between an individual that, um, if you just look at them from a movement and exercise perspective, has a very difficult time, uh, relaxing and, uh And, and relaxing sounds like such a silly word, but I mean that in a sort of a clinical sense, right? Like, if they can't let their ribcage down-

   28. JJJoel Jamieson49:29

       Yep

   29. PAPeter Attia49:30

       ... if they can't properly generate intra-abdominal pressure, if they can't go through a sequence of movements that generates some amount of motor control and compensatory relaxation contraction, um, I think there seems to be very high association between that and emotional stress and-

   30. JJJoel Jamieson49:44

       Oh, yeah
9. 50:43 – 1:04:45

   How Morpheus measures HRV using RMSSD and normalizes it to a 100-point scale for easier interpretation The Morpheus system: development, integration with various metrics, and personalized daily training recommendations to optimize fitness and recovery

   1. PAPeter Attia50:43

      Before we leave the measurement thing, I wanna go on to another one or two of those measurement-

   2. JJJoel Jamieson50:48

      Sure

   3. PAPeter Attia50:48

      ... um, and so at Morpheus, what do you guys use to measure?

   4. JJJoel Jamieson50:51

      So we use RMSSD, and then we use a log natural transform and a multiplier. That sounds like a lot of math but essentially, if you look at the data of RMSSD and you look at, like, a normal bell curve, it's skewed. It's non-normal. It's all the way to the left. So you get these normal ranges of, I don't know, 20 to 80 or 100, like you said, but then you can get an elite athlete's 180, 200, and so you have this big bunch of data on the far left-hand side that's kind of hard to interpret. So again, I'm not a statistician. I didn't create the formula. But essentially to normalize this data and make it look more naturally distributed, more like a normal bell curve, you do this log natural transform, you use the multiplier, and Morpheus ends up on a scale that looks more like a 100-point scale. So people with lower HRV are gonna be more like the 50, 60. People with more moderate, 60, 70. Higher, 70, 80. You know, elite athletes are gonna be 90 to 100. It's more of a scale that we have a more familiar relationship with, I would say, and the, the data is more normalized from a, uh, from a standpoint of a bell curve. So it's just an easier to interpret, but that's the reason for it.

   5. PAPeter Attia51:52

      So do most people, when they start using Morpheus and they're also using, like, whatever other device they're using that's just a purely RMSSD device, how much discordance are they typically seeing between them?

   6. JJJoel Jamieson52:06

      Really depends on what other, what they're using, right? There, there can be a big difference between the device that they're using and the numbers they're getting. But the, the trends should generally line up. If you're seeing Morpheus increase as a whole, you should see the other one increase as a whole. You should see the directional change matching, but the actual numbers will be somewhat different depending on where you're at in that spectrum.

   7. PAPeter Attia52:26

      So let's now talk a little bit about Morpheus. I've alluded to it a couple of times. So, um, it's a, it's a product I've been using for about a year and a half, maybe close to two years. Um, but before I talk about my experience with it and why I use it, right? Like, I'm, you know, everything I do, I do for a reason. [laughs] I'm a very deliberate human being. Um, so there's a very particular use case that is pretty narrow for how I use it. I, I, I, I'm, I know that I'm not using it to its full potential, but, uh, tell folks what this is about, your, your involvement in this, and that's obviously how we got to know each other.

   8. JJJoel Jamieson53:01

      Yeah, I mean, when I started using the old system, I had to wait for people to come in the gym to measure them, and so I realized I was getting a pretty small snapshot of what their life story was because I might measure them two or three times a week. Sometimes they'd come in the morning. Sometimes they'd come in the afternoon. And I realized the limitations of that. This is back in, you know, 2007 or '8. And so I wanted to create something that people could use with their phones and that we could get way more data from, and that was my first system, BioForce HRV, 2011. And that was really one of the earliest HRV apps out there where we could, you know, take your phone, you could do a recording, and you could get your HRV on your own. You didn't need, uh, to come into the gym. And one of the limitations of that was all I could look at was your HRV. I didn't necessarily have any idea what else was being tied to that, and so I could look at the change and ask you a bunch of questions and maybe try to figure out what those changes were coming from. But I wanted to create something that also tied in training and sleep and subjective markers and other metrics so that as a coach, I just had a more complete story of what was happening. And so that was really the genesis of, of Morpheus, and I started that in 2016, 2017, so, so quite a few years ago. And basically what we're doing is we're measuring HRV, and then we're tracking activity, sleep, workouts, all that sort of stuff. You can use the Morpheus device for a lot of that, or you can use other devices. So if you're using an Apple Watch to track your activity, your sleep, or a Garmin, we'll pull that data in. But what we're trying to do is take that HRV... This is, this is something we should definitely talk about. There's a lot of apps that give you HRV, and then you can either say, "Okay, I'm gonna interpret what this means myself, and I can try to figure out what these changes are. It's a physiological metric." Or you can say, "The apps are giving me a re- recovery or a readiness or some gauge that's based on that." Now, this comes back to every app's doing this completely differently, right? Where we have a lack of standardization across not just the HRV measurement, but then how that information's interpreted to generate recovery or readiness or some sort of number that the person in the app is saying, "Oh, my recovery is 80%," or-

   9. PAPeter Attia55:02

      Yeah

   10. JJJoel Jamieson55:02

       ... "My readiness is..." Right? These are just numbers that we are creating as a way to try to interpret the data, and then some of those apps, I think, do a reasonable job with it. Some of them don't. Um, but I created Morpheus and this idea of the re- recovery score based on what I had seen using HRV for 20 years, or maybe 15 years at that point. It's just a metric of what's appropriate for you on a given day. What is your body more likely to benefit from? And so we should probably talk about Again, what is recovery? What is readiness? Because those are metrics that Morpheus gives you, and Oura gives you, and Whoop gives you, and Garmin gives you, like, a body battery or every kind of app has their own gauge of that. But then the question is, how accurate is it? What does it really mean? And I think that's where a lot of confusion also comes in because we're trying to take metrics and turn them into something that's not a physiological measure, but something we try to create.

   11. PAPeter Attia55:52

       Yeah, I mean, look, I used an Oura Ring for many years, uh, probably haven't used it in a, a year, year and a half. There, you know, there's better devices I can use to track my sleep now. Um, and their recovery score, as you said, even if you believe the, that the score is accurate, and there's no reason to believe it necessarily is, um, more importantly, it's not something you can act on, right? So let's just say you believe the number and you say, "Okay, my recovery score is 80 today." And I, I certainly believe that if it spits out a 90 versus a 70, you know, your Whoop or Oura, there's probably a difference there. There's, you know, you're probably better off on the day you're 90 than the day you're 60. But how do you operationalize that information? And so when I was introduced to Morpheus, it was actually someone on my clinical team that said, "You know, we're having a hard time giving people real instruction around zone 2," 'cause most people don't want to do what you do, Peter. No-nobody wants to check their lactate levels and go through this. And I get it. I mean, I, I, I don't... I'd never fault somebody for not wanting to do a finger stick every time they do a workout. Um, and truthfully for some people, just relying on RPE can be challenging. So this person said, "Hey, look, um, the Morpheus app," and we'll talk about how it works, you know, 'cause I, I also appreciate how the measurement is taken. The Morpheus app gives you target zones for heart rate every day. And if you use the cutoff between what it's calling zone 1 and zone 2, that's a pretty good proxy for what your zone 2 is on that day.

   12. JJJoel Jamieson57:37

       Yep.

   13. PAPeter Attia57:37

       So I bought the system, um, and started using it, and I should show you the data 'cause I have recorded every single workout I have ever done for the last year and a half, and I record the following. I record the heart rate predicted by Morpheus for what my zone 2 is, the heart rate I largely end up at by RPE, and sometimes they're close. Usually they're quite close. Sometimes they're quite far. So sometimes Morpheus tells me to be at 138, but I'm kind of gassed out at 131, and sometimes it's the reverse. Sometimes Morpheus says, "You should be at 133," but I feel fantastic and I go to 140. What the power was for the interval and what the lactate is. And I have to tell you, Joel, I c- I cannot put in words how impressed I am with that system and how remarkably accurate it is at predicting something that is very difficult to predict. Um, so kudos to you for doing that. Um, what I find amazing are the days when... And I had one of these days a week ago. Morpheus said I should have been at 140 or 139 for zone 2. I got on the bike, and I did not feel great, and I sort of said, "I think Morpheus got it wrong. I'm gonna ride to this wattage," and my heart rate was about 132, and I checked my lactate and it was 1.1 millimole. I was nowhere near my limit of where I could have been that day. Now, again, we could get in the weeds on maybe that's fine. Maybe that's all I needed that day, and maybe I should have just been following how I felt. But if I'm really trying to get the right training effect, I was under-training a little bit on that day. Um, so, so I'll kind of pause there because I, I w- I want to kind of let you sort of interpret what I'm saying, um, and, and, and, you know, what you think of, like, why is it about that? 'Cause you spit out three zones.

   14. JJJoel Jamieson59:38

       Yep.

   15. PAPeter Attia59:38

       Zone 1, zone 2, zone 3, and I think you call them recovery and conditioning and both are low.

   16. JJJoel Jamieson59:42

       Yeah, it's just terminology, right?

   17. PAPeter Attia59:43

       Yeah, yeah.

   18. JJJoel Jamieson59:44

       It's just, it's just a way to gauge low, moderate, and high intensity.

   19. PAPeter Attia59:46

       Yeah.

   20. JJJoel Jamieson59:46

       It's all that.

   21. PAPeter Attia59:46

       Does it surprise you that... 'Cause I haven't told you this story before-

   22. JJJoel Jamieson59:50

       Yeah, yeah

   23. PAPeter Attia59:50

       ... in all of our communications. I don't, we've never talked about this particular issue. Does it surprise you that the heart rate that is on the cusp between your first and second training zones happens to correspond to this lactate of two sweet spot?

   24. JJJoel Jamieson1:00:03

       I mean, that was really the intent when I designed it, and that's, I think probably that's the difference in Morpheus I would say is when I designed it, it was as my experience as a coach for many years of testing lactate, of VO2 max testing, of HRV testing. I took a, synthesized a lot of information that I gained and a lot of knowledge and insight I gained to create this structured system of low, moderate, and high intensity. You can call them whatever you want to call them. That's basically what the zones are. And the biggest thing I realized is as people's autonomic nervous system changes, intensity and heart put, or heart rate changes, and you learn this over time when you see today a 140 is doing this, and tomorrow a 140 might be doing that based on changes in the auto- autonomic nervous system. And so when I created the algorithm, it was just based on a lot of data collected over a number of years of what I'd seen in the gym, what I'd measured, what I then looked back at the data. And so that was the end result of Morpheus, was trying to translate changes internally with how we can then turn that into smarter, more accurate and precise training, and that's what, you know, you're seeing with Morpheus. So it's awesome to hear that it's that accurate for you, and some people it's always gonna be much acc- more accurate than others. But as a whole, Morpheus is by far the best way to translate, you know, again, changes internally with changes we should be doing in the gym.

   25. PAPeter Attia1:01:16

       Yeah, I mean, basically for our patients now, we almost never bother with them checking lactate. It's basically, um, RPE if you can manage it. If you really have a sense of what zone 2 feels like, great. Um, but if you want some guidance Look, take the Maffetone formula, 180 minus your age, great place to start. Once you're getting a little more nuanced, if you want more guidance, use Morpheus and, and, and go to that, go to that heart rate. Um, again, tell folks how I get that number every morning. What am I... W- how is it spitting out that number for me? It's, I have to do a measurement, right?

   26. JJJoel Jamieson1:01:50

       Yeah, I mean, you have to measure your HRV, and then we're looking at other things that you've done in the past 24 hours if you're recording it. Um, and then based on your fitness level, so we ascertain your fitness level by looking at your resting heart rates, by looking at your average HRV, um, by looking at some of your heart rate trends when you're training, and we say, "Okay, Peter's roughly at this level of fitness. Peter's autonomic nervous system is responding in this way," which again con- correlates to how it's gonna react today. If I'm fatigued, then it's gonna take more energy to produce the same level of power output. And then we estimate, like you said, what for you is this cutoff between low m- low intensity, moderate intensity, and high intensity. And a, a way that people can think about this, I would say, is muscle fiber recruitment. So low intensity is primarily slow twitch muscle fibers doing the majority of the work, and specifically in zone two we're talking about where they're mostly oxidizing fat as much as possible. Kind of this moderate intensity, we're starting to recruit some of those moderate threshold fibers, and we can talk about what that means. But we're starting to recruit some of those m- those, those faster twitch, higher threshold muscle fibers. And then higher intensity, we're starting to really recruit all the muscle fibers and the highest intensity muscle fibers. And so as Morpheus is looking at this, it's basically saying, "Okay, roughly at this heart rate, we think this is the level of intensity that is gonna correspond to these low, medium, and high." And then it's giving the ability to just plug into Morpheus and say, "I wanna do zone two." Morpheus says, "Okay, based on what we've seen, this is where we think your zone two is for you today." And other zones, the same thing.

   27. PAPeter Attia1:03:16

       Yeah, and again, I just wanna reiterate, this is why it's very valuable. Like, it's actually giving me the prescription every single day. Um, when I got it, I was a little surprised 'cause I didn't, you know, I sort of bought it sight unseen. I was just kind of told it's valuable, but I didn't understand the nuance. So the thing shows up and I realize, oh, every morning I need to do a-

   28. JJJoel Jamieson1:03:36

       Yep

   29. PAPeter Attia1:03:36

       ... two and a half minute lay down in bed before I get up, still test, um, measuring my heart rate. And I guess you can do that, Morpheus at the time came with a chest strap and an arm band. I think it now is just a chest strap, right?

   30. JJJoel Jamieson1:03:49

       Yeah.
10. 1:04:45 – 1:13:26

    The benefits of morning HRV readings for assessing daily readiness compared to overnight HRV measurements

    1. JJJoel Jamieson1:04:45

       Exactly.

    2. PAPeter Attia1:04:45

       So your training zones change with every day. So one of the things that surprised me, Joel, was like, wait a minute. I'm used to having to measure HRV over the course of a night. What is the difference between what my Oura Ring used to tell me by measuring over eight hours of sleep versus this thing that's telling me in two and a half minutes in the morning before I've gotten up? Like, h- how do you think about that?

    3. JJJoel Jamieson1:05:09

       Yeah, this is, I think this is, this is probably the most important part of HRV because there is so much confusion on this. We look back historically, all the data that's been used, these all-cause mortality studies and all the different pieces of literature out there, 95% of them are from spot HRV measurements, that we are measuring at a specific time, and you're doing this in standardized conditions as much as you can to get a baseline. Because we wanna know where is your autonomic nervous system right now-

    4. PAPeter Attia1:05:35

       Same time every time

    5. JJJoel Jamieson1:05:36

       ... same time every day, the same conditions. Because what I wanna know is last, you know, 24 hours, you did something yesterday, you did lots of things, I assume. You ate food, you maybe worked out, you maybe had alcohol or maybe you didn't, you did mental stress or maybe you didn't. You put your body in a situation where it had to respond for, for the majority of the day to do something, and then you went to bed, and we wanna see the result of that. We wanna see this stress and recovery cycle that you went through yesterday because that tells us where your body's at right now. How is it responding? Because we'll look at changes over time and understand how your body is, is adapting to the world around you. And that's what most HRV has been built on, is we measure in standard conditions, we see where you're at today, and that informs us about what happened over the last 24 hours and, and maybe slightly beyond. And the analogy is if I was gonna weigh myself, I'd wanna weigh myself first time in the, first thing in the morning in standard conditions. I wouldn't wanna have a meal and then go weigh myself. I'd wanna have very standard ways of measuring so I can see the changes. Because ultimately it's you changing against yourself that's the most informative. So we wake up, we measure HRV, we see where you are, and we see where you were, what your averages have been, what your variations have been, and that tells us where you are today and that helps us make a decision about what are you ready to do right now, or what's the most appropriate for you to do right now. And one thing I'll say is if your HRV is high or low, we can talk about what those mean.

    6. PAPeter Attia1:06:57

       Yeah.

    7. JJJoel Jamieson1:06:57

       It doesn't mean that you can't train hard. It just might mean that, like, that might not be the most beneficial thing for you, and there might be a cost associated with that. If I wake up and my HRV is way f- outside of normal, you can't say, "Oh, I can't work out today." You can, you can, it's just a question of is that what your body needs? Um, but anyway, if you sleep-

    8. PAPeter Attia1:07:14

       Yeah, to be clear, I don't think I've... I mean, I don't think.

    9. JJJoel Jamieson1:07:17

       Yeah.

    10. PAPeter Attia1:07:17

        I have never once not exercised as a result-

    11. JJJoel Jamieson1:07:20

        Yeah, exactly

    12. PAPeter Attia1:07:20

        ... of what that said. And there have been days when I've had abysmal scores. Um, and it's told me, like my rate of what it, my heart rate range on what it has told me is never above about 141. There have been days it's been as low as 121, which for me means like my recovery was 35% or 40%. That's a night when I didn't sleep-

    13. JJJoel Jamieson1:07:40

        Sure

    14. PAPeter Attia1:07:40

        ... and something was dramatically off. You'd still do the workout

    15. JJJoel Jamieson1:07:43

        You still do the workout, right?

    16. PAPeter Attia1:07:44

        Yeah.

    17. JJJoel Jamieson1:07:44

        You just are aware of what the cost of that workout will be, and you might make adjustments tomorrow-

    18. PAPeter Attia1:07:47

        To-

    19. JJJoel Jamieson1:07:47

        ... or to your plan. Um, so any- you know, that's what we're getting when we're measuring at the end of sleep, right? The morning time, we're seeing what was the result of our sleep, what was the result of our workout, so yesterday, everything else we did. If we're measuring HRV overnight, HRV number one is always higher at night because the parasympathetic system is... That dial is already turned up-

    20. PAPeter Attia1:08:06

        Mm-hmm

    21. JJJoel Jamieson1:08:06

        ... quite a bit because you're sleeping, where it's the highest.

    22. PAPeter Attia1:08:08

        Although for most people, Joel, they will see the reverse because, like, my RMSSD HRV overnight is lower than the d- log normal transform I get out of Morpheus.

    23. JJJoel Jamieson1:08:21

        Yeah, 'cause Morpheus, if you look at the actual RMSSD data, you would see-

    24. PAPeter Attia1:08:24

        Yeah

    25. JJJoel Jamieson1:08:24

        ... that you'd be higher at night. I know Morpheus is dif- is different, obviously.

    26. PAPeter Attia1:08:27

        And can we see that in the app? Can we- are we-

    27. JJJoel Jamieson1:08:28

        You can't right now. We've, uh... Honestly, when we first came out with BioForce and Morpheus, there weren't so many other apps to compare against, so it wasn't-

    28. PAPeter Attia1:08:35

        Yeah

    29. JJJoel Jamieson1:08:35

        ... as big a deal to not show the raw number. Um, so we chose not to, but now I think we probably will just because people do wanna compare. Um, but anyway, overnight, that dial of that parasympathetic system is already higher.

    30. PAPeter Attia1:08:45

        Mm-hmm.
11. 1:13:26 – 1:21:26

    The impact of consistent exercise, stress, alcohol, and other lifestyle factors on HRV

    1. PAPeter Attia1:13:26

       Um, okay, so let's talk a little bit about the question that I'm sure is on everybody's mind, which is, uh, I've been doing this for a while, and I get that at the individual... You know, for my data, my... I see my up and down level, and I know that, hey, when it's higher, I'm generally gonna perform better, and I can push a little harder. When it's lower, I'm probably not gonna perform as well and maybe need to make that a little bit more of a, a, a less hard day. Um, but, [clears throat] but then you get this question of, hey, like- What can I be doing to improve the quality of my health in a way that is measured by this output of HRV?

    2. JJJoel Jamieson1:14:04

       Sure. I mean, this is where HRV is driven by, like, to genetics, fitness, primarily cardiovascular fitness is the biggest thing we see correlating drive it, and then obviously lifestyle. So doing things in your lifestyle that make that sympathetic dial come down when you don't need it, and doing things that turn on that parasympathetic dial when you're not using this, is going to put you in your highest level of your particular range, right, from a lifestyle perspective. And that's where I think most people underestimate the lifestyle impact on HRV and training everything else. They don't realize if you're stressed out from work six, eight, 10 hours a day, you're running around chasing your kids, you're doing all these things in, you know, your daily life, that has a pretty significant impact on your HRV because that sympathetic dial will be turned up for hours on end. Maybe not the same degree, of course, as a workout, but hours on end. So a lot of it comes down to just the stuff we know in everyday life that makes us healthier, right? Eating healthier foods, making sure we're getting enough sleep, managing our, our mental stress effectively, doing things that allow us to relax and turn that parasympathetic dial back up and that sympathetic dial back up, down, and then build VO2 max. You know, use strength training to-

    3. PAPeter Attia1:15:14

       So do you think it's more impacted by peak aerobic fitness or by, uh, base aerobic fitness? So is it, would you say it's more impacted by a higher zone 2 or a higher VO2 max?

    4. JJJoel Jamieson1:15:26

       I mean, they both contribute. Exactly how much, um-

    5. PAPeter Attia1:15:28

       Mm-hmm

    6. JJJoel Jamieson1:15:28

       ... you know, I couldn't say 'cause we don't, we measure, we tend to measure aerobic fitness from a peak standpoint for the most part.

    7. PAPeter Attia1:15:33

       Yeah. Yeah.

    8. JJJoel Jamieson1:15:33

       So that's probably what we-

    9. PAPeter Attia1:15:34

       That's more standardized

    10. JJJoel Jamieson1:15:34

        ... more standardized, what we would look at. But I think training frequency matters, which is where you get zone 2, right? You can't do VO2 max training five, six days a week. We do a lot more zone 2. We do a lot more frequency and volume of that, and I think that translates, uh, more than likely into a higher VO2 or into a higher HRV, even if you didn't go out and do a bunch of the zone 2 or the, you know, VO2 max type work.

    11. PAPeter Attia1:15:58

        Yeah. Um, and then tell me a little bit about sort of the, um, like what i-i- as far as... Okay, so one of the advantages, I think, of those overnight tests, uh, again, whether it's Oura, Whoop, Eight Sleep, any of these things, is, uh, uh, people have noticed how much of an impact alcohol has on overnight HRV.

    12. JJJoel Jamieson1:16:22

        Sure.

    13. PAPeter Attia1:16:22

        Um, it's probably one of the most profound changes you see in response to alcohol, and I would argue that a big part of the movement we're seeing around people drinking less can be attributed to those devices, which is giving people visibility into, "Oh my God, like, you know, I didn't realize that alcohol could have such a profound impact on this." Um, is that something... I, I, I guess that would kind of be out of your system maybe the next day, or would that still be there in the morning?

    14. JJJoel Jamieson1:16:52

        It, it, well, it, it would depend in the sense of if, if you had alcohol close enough to bedtime-

    15. PAPeter Attia1:16:56

        Yeah

    16. JJJoel Jamieson1:16:56

        ... it could impact your sleep, which impacts your recovery, which will impact the morning measurements. You'll still see some, some remnants of it, for sure.

    17. PAPeter Attia1:17:02

        Yeah.

    18. JJJoel Jamieson1:17:02

        Um, but yeah, you'll see that more directly in, in the overnight stuff. I think as a whole what we see is people become much more aware of things like alcohol, things like excessive stimulants or, you know, s- God forbid, smoking or, you know, just years of or massive amounts of chronic mental stress. Those things impact much more than I think people-

    19. PAPeter Attia1:17:19

        Yeah

    20. JJJoel Jamieson1:17:19

        ... realize. Example of this, we were measuring a college soccer team, um, across a couple of seasons, and we would see that during finals week, they would look far worse than during tournaments, even competitive, like fi- uh, playoffs, just because that stress of being, you know, in a finals week-

    21. PAPeter Attia1:17:39

        Yeah

    22. JJJoel Jamieson1:17:39

        ... where you're studying and you're not sleeping and you're, you know, more stressed out.

    23. PAPeter Attia1:17:42

        And what, well, give me a sense of the range that you would see. What, what, what would you see in an... Uh, like give me an average athlete where this would be their morning HRV under these circumstances, this is what it looks like when they're over-trained, this is what it looks like when they're in the tournament, this is what it looks like in finals.

    24. JJJoel Jamieson1:17:57

        Yeah, again, there's a lot of variability there.

    25. PAPeter Attia1:17:58

        Yeah.

    26. JJJoel Jamieson1:17:58

        Um, but from a college standpoint, most soccer athletes that we would see, and these are female athletes, would be in the low mid-80s on a, you know, normal basis. And this, again, this is Morpheus system, and that's, you can't compare these to other numbers.

    27. PAPeter Attia1:18:09

        Yeah.

    28. JJJoel Jamieson1:18:09

        Um, but they'd be in the low to mid-80s kind of as a normal range. We'd see them drop into the 50s, 60s, sometimes even 7- or 70s, sometimes down to 50s, which is in Morpheus is the-

    29. PAPeter Attia1:18:18

        That's, that's the stress

    30. JJJoel Jamieson1:18:19

        ... it's, it's, yeah, that was the stress of finals week. It's two, three, four days of not getting much sleep and s- you know, studying a lot and just working out very b- less or very sporadically probably compared to normal training sessions. You just see the impacts of life being very, very significant that people don't necessarily expect that because they feel like, oh, the workout's the most impactful thing. Well, it is in a way, but it's also only an hour, maybe two hours. It's the rest of your life that also adds up to a huge amount of stress if you are very, very stressed and if you're going through your life, you know, in a, in that kind of type A, I'm always turned on, I can't turn off my stress. That has a very big impact. I think, um, you know, Sapolsky, who I know you've had on the show-
12. 1:21:26 – 1:26:04

    Optimizing zone 2 training with Morpheus

    1. PAPeter Attia1:21:26

       Okay. Great, and again, my use case is quite simple, which is mostly just predicting that zone 2. But, but I have a feeling a lot of people listening to us will immediately y- you know, resonate with that use case 'cause I think for many people, there's still a little bit of ambiguity on not the concept of what zone 2 feels like, but the day-to-day variation-

    2. JJJoel Jamieson1:21:43

       Yeah, it's a lot

    3. PAPeter Attia1:21:43

       ... which again, is really significant.

    4. JJJoel Jamieson1:21:45

       And, and that speaks to the body's dynamic. You know, I think we, we can do a zone 2 test and look at lactate and all these things, but if we just take one test, we don't realize how much the body changes on a daily basis. And so if you just, "Okay, I took my lactate test six months ago. I'm just using this static zone 2," you're missing that dynamic change that the body's going through on a daily basis. The body's not static. I m- m- I measure blood pressure, I measure testosterone, I measure... Like, all these numbers change-

    5. PAPeter Attia1:22:09

       Yeah

    6. JJJoel Jamieson1:22:09

       ... constantly. Like, the body doesn't sit still.

    7. PAPeter Attia1:22:11

       A- and I wanna make another point, which is people, again, might be listening and saying, "You know, Peter, man, it's too much data, dude. Just go out there and do it." And I, and I'll, I'll, I'll give you the counterargument to that. When I was a competitive athlete and I was training 28 hours a week, I had the luxury of junk miles. I didn't always have to be perfect, but I'm not a competitive athlete. I'm a competitive father. I, I, you know, I'm running three businesses. Like, I don't have the time for nonsense. Every minute I'm training, I have to get the training stimulus right or at least as close to right as possible.

    8. JJJoel Jamieson1:22:49

       Yep.

    9. PAPeter Attia1:22:50

       So when I'm setting out to do zone 2, I gotta do it, and if I'm out there trucking along and my lactate's 1.1 or 2.9, I'm missing the training effect I want. So the more insight I can get to narrow that down, the better, because I'm, I'm only gonna give three hours a week or four hours a week to that training. I'm not gonna put 12 hours into it where if, if I do 12 hours and I screw up three of them, who cares? I still got nine.

    10. JJJoel Jamieson1:23:17

        Sure.

    11. PAPeter Attia1:23:17

        So, so that's why I, I know that there are people watching this saying, "Dude, you're a psycho," and it's like, "No, I'm just efficient with my time, and I don't wanna waste my time."

    12. JJJoel Jamieson1:23:26

        I, I think what it comes down to is each person has a certain amount of training in a week they're gonna... I like, I think it's a weekly basis, right? 'Cause that's kinda the cycle we live in. There's an amount and a type and an intensity of training that you are individually going to respond the best to, and if you go above it, not so great things are gonna happen. If you go below it, you're, you're not gonna get the outputs you want. And that amount is not easy to find, and it changes on a weekly basis. It's not the same-

    13. PAPeter Attia1:23:52

        Yeah

    14. JJJoel Jamieson1:23:52

        ... week in, week out. And so the more that you can hone in on that core how much volume do I need and how much intensity do I need, if you can get that right week in and week out, you will see continual improvements, and that work will turn into result. If you don't answer that correctly, bad things happen. You either waste your time because you're not getting as much out of it as you could, or you do end up over-trained, in which case we see injuries and we see burnout and lots of things that are gonna have negative health consequences. So I think ultimately what you said is, "I wanna use information to make sure that I am getting the most bang for my buck, the best result for the amount of work I'm putting in," and that's where I think data can play a really powerful role is it's information that you can use to make much more granular decisions around rather than just guessing, "Oh, I should go do 40 minutes today." Should you? Or, "I should do 200 minutes this week." Is there anything to support that-

    15. PAPeter Attia1:24:42

        Yeah

    16. JJJoel Jamieson1:24:42

        ... other than just throwing stuff at the wall and seeing what sticks? And I think that's what intrigued me so much about HRV is it felt like I could open the black box and get some real answers other than, like, test, train for eight weeks, remeasure, see what happened.

    17. PAPeter Attia1:24:55

        Yeah.

    18. JJJoel Jamieson1:24:55

        I don't wanna wait eight weeks. I don't wanna potentially lose the gains I could've made across that time period. So for someone like yourself that's, again, wanting to get as much out of their time as they possibly can, yeah, data can play a really strong role in that 'cause it can answer questions that can't be answered otherwise.

    19. PAPeter Attia1:25:09

        Yeah, and, and I think it only gets more significant as we age. Uh-

    20. JJJoel Jamieson1:25:12

        100%

    21. PAPeter Attia1:25:12

        ... you know, when I, when I was 40, my recovery capacity was so much greater than now, never mind 30, 20. That's obvious. But, but even the difference between 40 and 50 is, is significant, and, um, I know there are a lot of people listening to us right now who can relate, right? They're sort of like, "Hey, I'm getting a little bit older."

    22. JJJoel Jamieson1:25:30

        Yep.

    23. PAPeter Attia1:25:30

        "I don't feel as great as I did." I... So it's, it's a question of time and age, and, and I think the further we get along that, the more this type of system, um, a- again, for me, I, I, I, I can't say enough about it. Um-

    24. JJJoel Jamieson1:25:42

        Yeah, I think, um, age reduces your margin of error-

    25. PAPeter Attia1:25:44

        Yeah, exactly

    26. JJJoel Jamieson1:25:44

        ... is what it comes down to. I mean, I'm 44, and, you know, like, you can do a lot of things wrong in your 20s and maybe in 30s, and you can still get a lot of benefit out of it 'cause you just can res- you're so resilient. Your, your metabolism will adapt. But like you said, the older you get, the, the less you can do that, and so you, you have to be much more acutely aware of what your body can and can't do, and that's part of what HRV can help you understand.

13. 1:26:04 – 1:32:35

    Using heart rate recovery (HRR) as an indicator of athletic conditioning and the balance between aerobic and anaerobic systems

    1. PAPeter Attia1:26:04

       You said something maybe 20, 30 minutes ago, and I, I jotted a note down 'cause I didn't wanna, um, derail us at the time, but I'll come back to it now. So, um, when I'm doing my VO2 max sets, the thing I monitor for every set is heart rate recovery.

    2. JJJoel Jamieson1:26:18

       Yep.

    3. PAPeter Attia1:26:19

       So as soon as I get to the top, 'cause I do those on a hill, so as soon as I get to the top of the hill, I hit a timer, I hit the lap timer, and I count how many beats does my heart rate go down in the first 60 seconds at the completion of the interval, and that's a great proxy for-

    4. JJJoel Jamieson1:26:34

       It is

    5. PAPeter Attia1:26:34

       ... how I'm doing. Um, so I've got kind of my normal range should be 30 to 35. On a really good day, I'm 40 to 45, and a week ago or so, I had, like, one of the worst days I've ever had where I was, like, 19 to 21 in a minute. That's all I could recover. I mean, I was smoked. Uh, now I didn't sleep the night before, so I think, you know, I made an Instagram post about it because I thought it was just a great sort of illustrative teaching point. You said something that made me wonder about another test. Would there be any utility in right after a VO2 max interval doing an HR-

    6. JJJoel Jamieson1:27:11

       Absolutely

    7. PAPeter Attia1:27:11

       ... heart rate variability test-

    8. JJJoel Jamieson1:27:12

       Oh, heart variability

    9. PAPeter Attia1:27:13

       ... to see how much sympathetic tone can I dial down and how much, how much parasympathetic tone can I dial up after what's probably a peak, you know, a very high sympathetic, low parasympathetic exercise?

    10. JJJoel Jamieson1:27:25

        Sure. Yeah, you, you can, you can do that, actually. I mean, it's very specific. Like, you can't move around if you wanna get some standardization to it. So yeah, you could, you could do a 10, 15-minute recovery period. Steven Seiler, the guy who's-

    11. PAPeter Attia1:27:35

        What if I just did it right at the top? Like, literally would that be too much?

    12. JJJoel Jamieson1:27:38

        Prob- probably. I think, honestly, I think heart rate recovery is, it illustrative-

    13. PAPeter Attia1:27:42

        Is far better for that?

    14. JJJoel Jamieson1:27:43

        It's, well, it's illustrative of what you wanted to get to because-

    15. PAPeter Attia1:27:46

        Okay

    16. JJJoel Jamieson1:27:46

        ... what we see is heart rate recovery is driven by what? The reactivation of the-

    17. PAPeter Attia1:27:49

        The balance of those two

    18. JJJoel Jamieson1:27:50

        ... it's, it's turning the sympathetic down as quickly as possible and turning the vagus, the parasympathetic, up as fast as possible. So heart rate recovery is already giving you that information without having to get as granular as pulling out the R- the beat to beat.

    19. PAPeter Attia1:28:02

        I see. Got it.

    20. JJJoel Jamieson1:28:02

        You don't necessarily have to get that level of detail. You can just see the heart rate drop, and that drop is being caused by the increase in heart rate variability. And what's really fascinating is they used to think, and this is pretty new research I was, I've going through, we used to have this idea that when your heart rate increased above 100 beats per minute, that there was really no vagus input, that there was almost no parasympathetic, and, and they figured that because they would look at acetylcholine as essentially they could block it into the heart, and they'd say, "Oh, we block acetylcholine from vagus and the heart still pumps just fine during exercise. Exercise must not be vagally driven at all." But what they found is that the vagus might actually be turned up a bit during exercise in some sense because it can increase coronary blood flow by increasing vasodilat- dilation-

    21. PAPeter Attia1:28:48

        Mm

    22. JJJoel Jamieson1:28:48

        ... in the coronary artery. And so HRV is probably not r- or part... the vagus, I should say, is probably not completely inactive.

    23. PAPeter Attia1:28:54

        Completely off. Yeah.

    24. JJJoel Jamieson1:28:55

        You know, it's probably not completely off. It's this, it's this ratio. It could be turned up, but the sympathetic system is turned up so much more, and it's using a different mechanism. We don't see the heart rate variability high, obviously, but it's probably more ready to turn that back up even further as soon as that sympathetic system starts turning down, and we're dropping our, you know, our adrenergic hormone levels, our catecholamines, all these things are dropping pretty quickly, and the faster we can turn that parasympathetic up, the faster our heart rate comes down. The other thing that's interesting is they've looked at heart rate recovery in terms of it represents to some extent the balance of the aerobic and anaerobic systems that contributed to that exercise. So the more aerobically driven something was, the faster our heart rate drops. Because in a lot of ways, higher heart rates are driven by that sympathetic and by the anaerobic pieces-

    25. PAPeter Attia1:29:39

        Mm

    26. JJJoel Jamieson1:29:40

        ... of metabolism. So-

    27. PAPeter Attia1:29:41

        What do you see in, uh, young el- exceptional athletes? I mean, I, I wish I had tracked this metric when I was a teenager.

    28. JJJoel Jamieson1:29:48

        Yeah.

    29. PAPeter Attia1:29:48

        Like, I wish I know how much my heart rate recovered then, um, back when my peak heart rate was 205 to 210. Uh, what, what do you see in these young-

    30. JJJoel Jamieson1:29:58

        I mean, on really good numbers
14. 1:32:35 – 1:38:37

    The importance of tracking HRV trends over time rather than focusing on data from a given day

    1. PAPeter Attia1:32:35

       Um, I wanna go back to kind of what we were talking about on the, the trailing average of HRV data. So again, I, I think the, uh, so I'm glad to hear that my failure to utilize Morpheus in every moment of the day isn't really impeding its fidelity. I kind of know that because, again, as I said-

    2. JJJoel Jamieson1:32:54

       Yeah

    3. PAPeter Attia1:32:55

       ... it just, it's so damn accurate in what it predicts. It's like a shaman.

    4. JJJoel Jamieson1:32:58

       [laughs]

    5. PAPeter Attia1:33:00

       Um, but what amazes me and what I'm sh- I, you, you, you have the patience of a saint, Joel, because I email you so much, it must be infuriating.

    6. JJJoel Jamieson1:33:08

       [laughs]

    7. PAPeter Attia1:33:09

       But what amazes me is how sometimes the data I see, I don't believe it. And, and you, you're always like, "Yep, but you gotta look back at what it did seven days ago and six days ago and five days ago."

    8. JJJoel Jamieson1:33:20

       Yeah.

    9. PAPeter Attia1:33:20

       And so w- walk me through kind of the, the arc of the HRV over time and how, you know, the undulation of the HRV-

    10. JJJoel Jamieson1:33:34

        Yep

    11. PAPeter Attia1:33:34

        ... matters as much as the HRV on a given day. This is-

    12. JJJoel Jamieson1:33:38

        Yep

    13. PAPeter Attia1:33:38

        ... this is the part that is totally news to me. And, and again, I, I think the proof is in the pudding because at least for me, this seems to really work.

    14. JJJoel Jamieson1:33:47

        Sure. Yeah, I mean, again, we're looking at not just what is your number, but what is your number in relation to where you're usually at. And we're looking at how much does our number move today versus what's, like, a normal movement for you. And again, we're looking at just this manipulation of dials by the autonomic nervous system. So what Morpheus is doing is looking at your seven days and seeing, okay, what's kind of your normal baseline number itself, but also what's your normal level of variability across those different time periods? And then we look at standard deviation. And so if we see big changes greater than one standard deviation away from your average, away from your baseline, we know that that's the autonomic nervous system responding to a greater input. It's, it's responding to more stress, and it's having to make bigger dial adjustments. And that tells us that you've been paying a higher cost because you put your body under more stress. And if we were to, probably to illustrate, to just isolate, like, let's say we put our bo- like, our body's in kind of a normal rested state, let's say, and then we do a single workout, and we allow it whatever necessary time it needs to recover. During the workout, obviously the body turns up that sympathetic dial. It turns down that parasympathetic dial. We produce more force, more energy, more power, blah, blah, blah. And then after the workout, like we talked about, the sympathetic system starts to come down. The parasympathetic starts to come back up. Now, depending on the workout you did, that could happen in very different timescales. And Stephen Seiler, again, uh, who really popularized polar training, he was just showing some stuff. If you do, like, zone 2 and below aerobic work, that recovery happens pretty quickly.

    15. PAPeter Attia1:35:20

        Mm-hmm.

    16. JJJoel Jamieson1:35:20

        Within a few hours, we'll see that parasympathetic system turn on, and it'll come up above your baseline to maybe 110, 120% of what your ac- HRV was at rest. So Morpheus, you know, if you were, I don't know, a 70, if you were to, if you were to theoretically remeasure it, you might be a 74 or 75. You would see a noticeable uptick above baseline because our body has been able to shift very quickly into that restorative phase by that vagus nerve firing more, uh, forcefully and turning up-

    17. PAPeter Attia1:35:49

        Hmm

    18. JJJoel Jamieson1:35:49

        ... the parasympathetic. So we see, again, suppression during the workout and this curve starting to come back up. During lower intensity workouts, we'll see it pretty quickly come up above baseline, and then kind of as your body went through that complete cycle and restored homeostasis and did what it wanted to do, it would then just kind of settle back down to where it started. And so you'd see this curve, this very clear curve. Now, in a much higher intensity-

    19. PAPeter Attia1:36:09

        But the amplitudes aren't as big.

    20. JJJoel Jamieson1:36:11

        The amplitudes aren't as big, exactly.

    21. PAPeter Attia1:36:12

        Yeah.

    22. JJJoel Jamieson1:36:12

        In a, in a much higher intensity, higher volume, even, even lower intensity, let's say you're doing two, three hours of it in heat, right? That's a much bigger stress. You'd see the same curve, but it would play out over a much longer timescale because it would take much longer for the body to restore back to where it was and then to get everything where you started with from a HRV standpoint. So we'd see a much bigger depression, a much lower, uh, drop, and then we'd see a much longer timescale for it to come back up to normal, and then we might see it come up above normal for some period and then, and then restore. But I'll say there's a big difference in the individual as well. People with higher HRV and people that are more fit, they're more likely to see this increase above baseline. Somebody who has less autonomic range, they can't quite turn that parasympathetic dial up as much, they might never get up above baseline. They might just kind of spend time getting back to that baseline HRV, and you never really see the peak above baseline, and then they're restored afterwards. So it's, it's an individual thing based on fitness, but we should generally see suppression of HRV, an increase of HRV, and then kind of a back to normal HRV. It's that process. Now, the tricky thing comes is we have so many other things influence it. Alcohol influences it. Mental stress influences it. Sleep influences it. So it's overlapping influences that will get to where you're seeing, but that's the core thing of our body responds to stress by dropping HRV and then by recovering HRV and then be- by coming back to whatever that normal range is.

    23. PAPeter Attia1:37:35

        Yeah, and that's why, again, I think it's not intuitive enough to just look at the HRV that given day.

    24. JJJoel Jamieson1:37:40

        Yep.

    25. PAPeter Attia1:37:40

        You can't just say, "My HRV was X today, and there's a one-to-one map between what my HRV is on a given day and what my training output should be that day."

    26. JJJoel Jamieson1:37:50

        Exactly. That's-

    27. PAPeter Attia1:37:50

        Because you need to know the first derivative, the second derivative, and frankly, even the, the arc that it's on.

    28. JJJoel Jamieson1:37:57

        Yeah. It's, it's, it is. It's, it's, it's an all-cause, you know, metric that's not just looking at one input. It's looking at everything. And so interpreting that output is not always the easiest thing in the world. And again, if you kind of look at it as like, oh, up is always one thing and down is always one thing, it's a little more nuanced than that because it's, again, it's this responsiveness of, okay, it's gonna drop after acute stress. Then it's gonna come back up. It might come up way above baseline and then kind of drop back down to normal. You know, this curve is not always the most intuitive thing to understand and, and, and that's part of the challenge, I think, with people just kind of looking at it and say, "Oh, it's this. I'm gonna go do that."

    29. PAPeter Attia1:38:29

        Yeah, I mean, it's, it's, uh, it's certainly not intuitive to me, which is why I annoy the hell out of you and pepper you with all these questions. Um-

15. 1:38:37 – 1:46:38

    Effect of GLP-1 agonists on heart rate and HRV

    1. PAPeter Attia1:38:38

       I want to change gears to talk about something, uh, that I've, I've alluded to a couple of times in the past, which is a phenomenon that we see in patients taking this new class of drug. I mean, it's not really a new class of drug. It's been around for a decade, but a class of drug that has gained a lot of popularity in the past, uh, probably two to three years, which is the GLP-1 agonists-

    2. JJJoel Jamieson1:38:58

       Mm-hmm

    3. PAPeter Attia1:38:58

       ... and the, um, the dual, the dual agonist with GIP as well. And again, we don't have an enormous and overwhelming body of evidence on this. You know, we don't have that many patients in our practice, and we frankly don't have that many that take it. But certainly over the past three years, uh, you know, I have to think we've seen two dozen patients on these drugs. And again, in all cases, we have overnight information on heart rate and heart rate variability. And so the unambiguous sign that we see is that resting heart rate is going up.

    4. JJJoel Jamieson1:39:31

       Hmm.

    5. PAPeter Attia1:39:31

       Um, and it's going up an average of 10 beats per minute with-

    6. JJJoel Jamieson1:39:37

       Wow

    7. PAPeter Attia1:39:37

       ... a range of about 7 to 12. Uh, and again, this is unmistakable. It's not subtle. And when they come off the drug, usually within a month, it goes back to normal, uh, for patients who do indeed go off the drug. We're also seeing a compression of heart rate variability. So we see heart rate variability come down, although that's less predictive. But I now realize we're kind of using the standard -- We're not using, like, a Morpheus. We're using kind of their Oura Ring or whatever, and, you know, maybe those data just-

    8. JJJoel Jamieson1:40:07

       They just aren't accurate

    9. PAPeter Attia1:40:08

       ... aren't as accurate.

    10. JJJoel Jamieson1:40:08

        Yeah.

    11. PAPeter Attia1:40:09

        Um, so my first question for you is, if there's something going on in a drug that is predictably driving heart rate up, would you expect it is also driving heart rate variability down? Do those tend to move in that opposite direction?

    12. JJJoel Jamieson1:40:23

        Generally speaking, yeah. Generally speaking, you'd see that. Now, just as you mentioned that, my thought would be it's, it's strong appetite suppressant.

    13. PAPeter Attia1:40:30

        Correct.

    14. JJJoel Jamieson1:40:31

        The vagus is very tied to appetite. So if you think about this, if we were to turn up that sympathetic dial, our hunger gets turned down.

    15. PAPeter Attia1:40:38

        Yep.

    16. JJJoel Jamieson1:40:38

        We don't really want to be hungry while we're in the middle of some stressor, right? But after that period of stressor is over, theoretically, we've burned energy. We need to restore and eat. And so the vagus is very connected to the gut and to hunger centers, and it feeds up into medulla, and it's controlled by hypothalamus. There's a very strong vagal relationship to hunger and a desire to eat. So I almost wonder if suppressing the vagus and decreasing, uh, HRV and increasing heart rate is a byproduct of how this is inhibiting appetite.

    17. PAPeter Attia1:41:08

        Yeah. Interesting.

    18. JJJoel Jamieson1:41:09

        That would make sense.

    19. PAPeter Attia1:41:10

        And, and, and so it's an interesting question because it, it, it, it, it then leads to another question, which is, if I told you that I'm going to change you in a way that your heart rate is 10 beats higher and your HRV is 10 milliseconds lower, you would say, "Well, whatever you did was negative."

    20. JJJoel Jamieson1:41:31

        Sure. I mean, there's a cost to that, right?

    21. PAPeter Attia1:41:33

        Right. Do we think that that could be the case here? I mean, again, we're really wildly speculating.

    22. JJJoel Jamieson1:41:37

        Yeah.

    23. PAPeter Attia1:41:38

        But, but this is... You know, I get asked all the time, "Peter, are these drugs safe? Are these drugs good? What do you think of them?" And I'm always say sort of the same thing, which is, look, clearly for some people, whatever unknown exists around these drugs is worth it, right? Like if you're -- if an individual l- you know, goes from being 250 pounds to 200 pounds and having a hemoglobin A1c of 7% to 5.5%, that is so positive for them that I think it justifies whatever unknown exists-

    24. JJJoel Jamieson1:42:08

        Sure

    25. PAPeter Attia1:42:09

        ... around these drugs, if there's no other way they're going to achieve that benefit. Um, but I'm really more interested in these marginal cases of people who don't have diabetes and want to lose 20 pounds, which by the way, might not really matter-

    26. JJJoel Jamieson1:42:23

        Translate anything

    27. PAPeter Attia1:42:23

        ... in their overall health.

    28. JJJoel Jamieson1:42:24

        Yep.

    29. PAPeter Attia1:42:24

        It's cosmetic. And are they taking too big a risk? That, that's kind of the question I'm interested in, and that's why I keep coming back to if it raises your heart rate that much and lowers your heart rate variability, is there -- is it, is it doing so -- is that -- are we picking up a signal that is just a niche representation of appetite suppression via the vagus nerve, or is it actually playing a role in the parasympathetic sympathetic dials?

    30. JJJoel Jamieson1:42:52

        I would imagine it's, it's gotta be... I mean, to move it that large, 10 beats is a fairly significant amount. I would-- can't imagine that's not having an actual effect on our ability to regulate ourselves effectively. We're probably in a more sympathetic state all the time, which is gonna have a cost. Now, if it's a few weeks or a month, you know, maybe that cost is relatively small. I don't know. Um, but if it's weeks or months and the-they're, they're living on this drug, yeah, there's-- I would suspect there's a real cost to that. And to your point, if it's -- the benefit is they lose a bunch of weight and all their blood markers improve, and we see health outcomes, maybe it's certainly worth-
16. 1:46:38 – 1:51:31

    Where HRV belongs in the hierarchy of health metrics

    1. JJJoel Jamieson1:46:38

       it up.

    2. PAPeter Attia1:46:39

       Let's take a step back and now just talk about where you think HRV belongs in the hierarchy of health metrics. Um, we, we've talked about so many different types of health metrics, and we've talked about how output metrics tend to be preferable, you know, or we can sort of think of them as functional metrics. Um, you know, I like an oral glucose tolerance test more than a hemoglobin A1C. One is kind of functional. It actually is a test. It watches how you do something. VO2 max, strength, those are more functional tests than maybe resting heart rate or, uh, muscle mass, right? Muscle mass is great. It's predictive, as is resting heart rate, but when you actually put the work out. Um, HRV is obviously a readout state. What... W-Where do you think on the dashboard of health longevity, uh, where, where do you, where do you place it?

    3. JJJoel Jamieson1:47:29

       You know, I think it's important to monitor as you're going along, but I would say if all your other metrics are telling you you're healthy and you're going the right direction, nine times out of 10 it's, we tell you the, the same thing. The, the point where I would be more, uh, aware of it is where it's very low and you don't have a reason for that. You'd want to figure that out. I've-- We've had people have arrhythmias they had no idea about, and they go to the doctor and they're, um, have some serious heart condition that they need to be aware of. But I would just say long term, it's, it should line up with VO2. It should line up with your metabolic markers. It should line up with all of this stuff. It's easier to track because we can measure it on a daily basis. I think that's probably the advantage I would say it has is you're not getting a VO2 max test every day obviously, or every week, every month. You know, you're not doing lactate testing. You're not doing these markers that are more output based that are really important frequently enough to get feedback of whether or not you're going in the right direction. So I think we can look at HRV in a more granular daily basis, just kind of say, "Am I going the right direction?" And that's probably more of a utility than a great predictor of, you know, something. And we can look at those daily changes to help us make more informed decisions. We can't do that with VO2 max or with, you know, more invasive tests. So it, it's a more, uh, you know, narrow data point, but it gives us something we can use more actionably than these longer term tests that I think are better actual measures of outcome. And if we see our HR- HRV trending down significantly, that is a warning sign we're doing something wrong. Our body is not adapting the way that it should be, and we need to make adjustments, whether it's to training or, or lifestyle. So I think it's used differently, right?

    4. PAPeter Attia1:49:00

       Yeah.

    5. JJJoel Jamieson1:49:00

       Like we use VO2 and we use, uh, those sorts of output measures as are we going the right direction and we have some prognostic value specifically from them. We use HRV to say, you know, are we more likely to be making improvements in the short term or are we heading the wrong direction where if we keep doing that for a long period of time, we're gonna either see the benefit or the cost depending which way, direction we're going. So I think they're, they're different.

    6. PAPeter Attia1:49:22

       Is there a number, Joel, on the, um, the log normal transformation you're doing on the RMSSD, a, a number below which if it's consistently there, you think that, you know, I would, I would want to inquire more?

    7. JJJoel Jamieson1:49:37

       50s, 40s. I mean, those are, those are pretty low numbers for, for a Morpheus user.

    8. PAPeter Attia1:49:40

       Okay. Again, just for folks listening-

    9. JJJoel Jamieson1:49:42

       And it depends on age too

    10. PAPeter Attia1:49:43

        ... that's not the RMSSD number.

    11. JJJoel Jamieson1:49:44

        Right.

    12. PAPeter Attia1:49:44

        Right? The RMSSD number might be far, far lower than that.

    13. JJJoel Jamieson1:49:48

        10.

    14. PAPeter Attia1:49:48

        Yeah.

    15. JJJoel Jamieson1:49:48

        You know?

    16. PAPeter Attia1:49:48

        Yeah.

    17. JJJoel Jamieson1:49:48

        Exactly. Yeah. So you, you really do have to be specific of what we're talking about, the systems. Um, but yeah, I mean, this is a, you know, N of one, but I was at a guy, his name was Mel Siff, who you probably aren't familiar with, but he was a very well-known sports scientist. He wrote a book called Supertraining. I was at his house with the original, uh, HRV system I was using, and I had all the metrics, and his RMSSD was like five. And he just looked really bad, you know? I said... And he'd heart, had a heart attack. And I said, "Mel, this looks really concerning." And he was, you know, he kind of brushed it off, and he died of a heart attack, uh, you know, a few months later. And so, you know, if you're really seeing these super low RMSSD or Morpheus numbers, like it's definitely an indication that that autonomic nervous system is not responding well to the world around it. If it's really, really low, you know, there could be a, a legitimate medical concern that's driving that. So if your, you know, Morpheus 40s, 30s and you're, you're just not getting up, it's probably worth looking into and it's something to definitely be concerned about.

    18. PAPeter Attia1:50:46

        And do you see the opposite where really high numbers or a sudden change from low to high can indicate an arrhythmia or something like that?

    19. JJJoel Jamieson1:50:52

        Yeah, ab- yeah, absolutely. You definitely do see these, these kind of weird numbers come out. You know, that could be arrhythmia, that could be medications, it could be who knows. You see some of these, these things jump around from anomalies that you just kind of like, "Eh, it's an artifact. I don't know what happened," and then sometimes you do see a medication or, you know, you see weird tech stuff with COVID, and you definitely see some weird stuff in the data that you want to be aware of that, you know, you probably wouldn't pick up otherwise. I would say HRV is more of a leading indicator in kind of how you feel, and some of those symptoms-

    20. PAPeter Attia1:51:20

        Hmm

    21. JJJoel Jamieson1:51:20

        ... can come days later.

    22. PAPeter Attia1:51:21

        Hmm.

    23. JJJoel Jamieson1:51:21

        So you'll oftentimes pick up something that looks weird, and then two days later you get a cold, or you get the flu, or you get some sort of, uh, thing that explained it.

    24. PAPeter Attia1:51:30

        Joel,

17. 1:51:31 – 1:53:50

    Parting thoughts

    1. PAPeter Attia1:51:31

       this is awesome. I, I, honestly, I feel like I know much more about this now than even after I did the AMA a couple of years ago, and I, I learned a lot to, to sort of prepare for that. So, um, a- a- appreciate it. I... And, and again, you know, I apologize 'cause on some level this, for some of the listeners, probably sounds like a bit of a Morpheus commercial at times.

    2. JJJoel Jamieson1:51:49

       [laughs]

    3. PAPeter Attia1:51:49

       But, uh, you know, obviously I have no affiliation with Morpheus, um, at all. Um, uh, but I point to it because, again, I'm a big consumer of data. I test every device out there extensively. Um, and I, I view it as the, you know, the stickiest device I've ever found for this use case. And so I do hope that people check it out. I think I just bought it online. It's a... You buy it direct to consumer, right?

    4. JJJoel Jamieson1:52:18

       Yeah, that's it, yeah.

    5. PAPeter Attia1:52:18

       I don't think you buy it on Amazon or whatever. Um, so, you know, I would encourage people to, if they want to take this to another level, that, that, that they should, uh, that they should check out, uh, Morpheus. I appreciate the work you're doing, Joel. I think it's, um, it, it's, you know, your, your... The, the, the curiosity and inquisition with which you bring to this is fantastic. Um, I, I benefit from it greatly and, and those are my patients who use it also as well. So thank you for both, you know, all the work you're doing and obviously coming here to talk about it.

    6. JJJoel Jamieson1:52:47

       Yeah, no, I appreciate being on here and being able to speak to your audience. I think the biggest thing I've learned after, you know, 20-plus years of coaching is we're all different. Um, and as much as it may be easy or, or attractive to say, "Oh, this is what somebody else is doing. Let me just try that. Let me just do the same thing," if you can spend the time just copycatting someone else's workout and really dig into your own physiology, how you respond to training, how you respond to diet, how you respond to different food intakes, really learn how your physiology works, you know, you will reap the reward to that in the long run. And I think that's where, you know, tools like HRV and sleep monitors, they, they build awareness. And whether you're using Morpheus or Oura or whatever else, using that data to really be your own coach and really understand your own, uh, physiology and your own biology, that's the ultimate way to get better results and, and have the health outcomes you're looking for. So I appreciate the opportunity to talk about that.

    7. PAPeter Attia1:53:38

       Thanks, Joel.

    8. JJJoel Jamieson1:53:39

       Thank you. [outro music]

Episode duration: 1:53:50