331‒ Optimizing endurance performance: metrics, nutrition, lactate, & insights from elite performers

1. 0:00 – 0:40

   Intro

   1. OBOlav Aleksander Bu0:00

      Seems like most things in our body is actually extremely trainable if you, if you, if you really s-- and that, that also comes back to the nutrition part as well, where exactly also the training programs we have today also is very m- ha- have not seen the same change as nutrition strategies have done over the last years as well. So that means also that the power numbers that was output maybe five, 10, 20 years ago, I'm not so sure if that's the limitation we are gonna see.

   2. PAPeter Attia0:24

      Especially late in races, right?

   3. OBOlav Aleksander Bu0:26

      Yes.

   4. PAPeter Attia0:26

      This is where it's gonna make a bigger difference.

   5. OBOlav Aleksander Bu0:28

      Yeah.

   6. PAPeter Attia0:28

      It's not gonna make a big difference at the beginning of the race, but it could make a huge difference at the end. [upbeat music] Hey, everyone, welcome to "The Drive" podcast. I'm your host, Peter Attia.

2. 0:40 – 3:24

   Olav’s unique approach to endurance coaching

   1. PAPeter Attia0:42

      Olav, thank you very much for coming, uh, to Austin on your way, uh, I guess you're on your way to Arizona?

   2. OBOlav Aleksander Bu0:48

      Yes, on my way to Flagstaff. So also thank you very much for having me again.

   3. PAPeter Attia0:52

      Yeah. Well, as, as I mentioned last time we spoke, um, I had a lot of notes. We got through, I think, one-eighth of them, so there's, there's kind of a lot to, to, to cover today. Um, and of course, as we've been sitting here for the last 15 minutes or so, um, we've already kind of [chuckles] started the podcast unfortunately, and I wanna go right to where we just left off, but I'm gonna resist the urge and kind of bring it, bring it back a little bit. So, um, you know, last time we spoke, uh, really about sort of the most nuanced ins and outs of, of cardiorespiratory fitness. Um, m- maybe just for the person who didn't catch that episode, can you give kind of the, the one-minute version of, of, of what you do and why you're, um, certainly one of the few people that would be poised to kind of talk about what we're gonna talk about today?

   4. OBOlav Aleksander Bu1:41

      Oh, uh, I'm not very good at the, let's say the, the pitches or the one-minute pitches.

   5. PAPeter Attia1:46

      Yeah, yeah, yeah.

   6. OBOlav Aleksander Bu1:46

      But no, um, what I do is that, um, my background is from engineering, and it means also that this principle have guided me quite a lot through my journey in endurance sports or in sports in general. Um, and, um, it, uh, I, I very much, uh, we, we embarked on a journey 10 years ago, more than 10 years ago, I would say now 15 years ago, where we started to do what I would call extreme in-depth and longitudinal studies on two of the arguably fittest athletes in the whole world. Um, and, um, yeah, I think that, uh, pretty much resembles it. We, we, we, we are obviously, uh, a large part of that also involves technology development simply because at we are, because we are at the edge of basically what we have available information, research on. And that means that in even in some cases, we have to develop technology to allow us to even, um, progress the understanding of, or, or, yeah, getting a more granular understanding of why things are the way they are.

   7. PAPeter Attia2:50

      Yeah, so in many ways, you're kind of an applied scientist.

   8. OBOlav Aleksander Bu2:53

      Yes.

   9. PAPeter Attia2:54

      And your laboratory is, is, is, is both a, a CPET lab and, and then a, a racing environment where mo- you know, most of the athletes you work with are triathletes, correct?

   10. OBOlav Aleksander Bu3:05

       Uh, well, um, yes and no. Uh, I would say that it's actually quite spread.

   11. PAPeter Attia3:09

       Okay.

   12. OBOlav Aleksander Bu3:10

       It's a mixture between triathletes, cyclists, runners, um, uh, yeah, track and field, uh, to, uh, even sailors, which is on the ex- let's say, on the explosive end of, uh, of the domain actually.

   13. PAPeter Attia3:22

       Yeah.

   14. OBOlav Aleksander Bu3:22

       Not endurance, but yeah.

3. 3:24 – 14:58

   Definitions of performance metrics: FTP, power, anaerobic threshold, & lactate threshold

   1. PAPeter Attia3:24

      I feel like we're gonna use a lot of terms today. We're gonna probably throw out the word anaerobic threshold, lactate threshold, VO2 max, FTP. So I just wanna make sure everybody kind of understands those things. So let's just take them one at a time. Um, can you define FTP or functional threshold power for folks?

   2. OBOlav Aleksander Bu3:41

      Uh, yes. Um, there is a couple of definitions of this already, which is I, I, I have to say that it's, um, it's bad when you have good, um, terminologies, but they start to get diluted.

   3. PAPeter Attia3:53

      Mm.

   4. OBOlav Aleksander Bu3:53

      But the original, uh, definition of FTP, um, by the authors, I think, was Andy Coggan.

   5. PAPeter Attia3:59

      Yeah, Andy Coggan. Yeah.

   6. OBOlav Aleksander Bu4:00

      Uh, and that was that basically it's the, you, you take-- You first actually have to do a five-minute all-out effort, and then basically there's a short pause in between there, and then you go to a 20-minute all-out effort, and then you subtract, uh, 5% from that to find your FTP. So typically it would be your 20-minute all-out minus, uh, 5%. And the reason for that is to try to get a ballpark-ish idea of what your, let's say, your, uh, power, your sustainable power output is possible to do over, uh, an hour. But as we have learned over the years is that, one, we figure out that this is not as accurate always because there are a couple of other things in there, and also, unfortunately, there have become different ways to doing it. Like some people, they just do a warm-up, and then they do a 20-minute all-out, and then they subtract 5%, and that's already different.

   7. PAPeter Attia4:47

      Yeah, we used to sometimes do 20 minutes and subtract 10%. So we would do a gentle warm-up-

   8. OBOlav Aleksander Bu4:53

      Yeah

   9. PAPeter Attia4:53

      ... for an hour.

   10. OBOlav Aleksander Bu4:55

       Yeah.

   11. PAPeter Attia4:55

       Then do 20 per- 20 minutes, and then subtract 10%. So yes, we're already-

   12. OBOlav Aleksander Bu4:59

       Yeah

   13. PAPeter Attia4:59

       ... kind of... But I guess the spirit of FTP, which is maybe what we want people to think about and not get mired in the details, is it really approximates kind of, um, an energy zone, right, that is, you know, more than just an all-out, but clearly less than what you could hold indefinitely, and it's directionally about the highest output you could have for an hour. Um, and there's different ways to approximate it, of course.

   14. OBOlav Aleksander Bu5:25

       Yeah. And I think maybe more importantly to that point is that, uh, as long as you do something consistently, so you keep the same protocol, you could say, okay, this one thing is the, the original, uh, let's say, thinking, and that went into, uh, devising this kind of protocol. But I would say more importantly is rather to stay true to the, to the principle of how you do it.

   15. PAPeter Attia5:45

       Yep.

   16. OBOlav Aleksander Bu5:46

       So as long as you do it the same way each time, this is more important. Yeah.

   17. PAPeter Attia5:50

       Yeah. And then how does that differ from another term that is used, uh, interchangeably, but I believe erroneously, which is critical power?

   18. OBOlav Aleksander Bu5:59

       Uh, so critical power is more, is something that you normally more, uh, extract from that you do multiple, uh, multiple, uh, all-out efforts, and then you apply, um- uh, reverse extrapolation to this to basically figure out what is your, uh, critical power. So it's more, it's a more of a little bit more advanced mathematical approach to it. But you do, uh, typically, you would say that there, there, there are different concepts to this. Uh, I personally have to say I like the critical power approach a little bit better.

   19. PAPeter Attia6:31

       And what is it trying to approximate?

   20. OBOlav Aleksander Bu6:34

       So critical power is basically, uh, where you, uh, try to, let's say, your m- mainly you could say you try to divide, uh, something into two zones or, well, that's, that's a, that's a crossover simplification. But you, you dis- dis- you distinguish between, let's say, a non-severe and a severe state, or basically where you are, again, also in the same way as FTP, trying to figure out what is the power you are capable of staying at for a prolonged time, and basically where you go into a territory where, let's say that, uh, small changes has a-

   21. PAPeter Attia7:12

       Con- huge consequences

   22. OBOlav Aleksander Bu7:13

       ... yeah, huge consequence on, on the duration that you're capable of holding it. Yeah.

   23. PAPeter Attia7:17

       And where does critical power typically lie in relation to FTP?

   24. OBOlav Aleksander Bu7:21

       Again, this depends a little bit on how you test FTP, but I would say that n- uh, how maybe FTP have been used over the last, uh, or let's say a little bit like, or deviated from how the, uh, authors originally devised it, I would say that it actually is not too different. And normally you would say that critical or functional threshold power, uh, would lie slightly lower in, in, in this, in power output than critical power. Um, but again, it depends very much on, let's say also in critical power there are today, I don't know how many different definitions there are of critical power and how you should do the protocol there. Um, but it means that, um, normally critical power, if you look at it from a metabolic perspective, it sits somewhere between your, uh, your maximum lactate steady state, or call it anaerobic threshold, uh, and, uh, VO2 max. So it typically more close to, um, VO2 steady state or, uh, and so on, but that's introducing another term that, uh-

   25. PAPeter Attia8:20

       Yeah

   26. OBOlav Aleksander Bu8:20

       ... just doesn't, uh, bring clarity to the, uh-

   27. PAPeter Attia8:24

       Yeah. We'll, we'll, we'll define those in a second

   28. OBOlav Aleksander Bu8:26

       Yeah.

   29. PAPeter Attia8:26

       Um, [clears throat] so many of these metrics, FTP, critical power, um, are, are easiest to think about in terms of, uh, uh, cycling because we use power meters. Um, do the same concepts still apply in swimming and running?

   30. OBOlav Aleksander Bu8:41

       Yes, uh, I would say. Um, and I, I... One thing that, uh, is, uh, I think for the sake of simplicity, it sometimes re- it helps to refer to, like say, one condensed number. So you use, for example, you can say critical pace, for example, in running and, and swimming, and the way of testing it is not too, uh, let's say, uh, different to what you would do in cycling. Um, but one thing that I want, one thing that actually happens in the process is that you actually have access to more granular information, and you are dumbing down information a little bit when you call it FTP or you call it critical power. Because more importantly, I would say, is that when you, when you make, when you, when you present a critical power number only or an FTP number only, you have taken two-dimensional information and, and made it one-dimensional, uh, meaning that you only look at the Y-axis and you, you take away the information that is quite cri- critical, I would say, and that is how long are you able to, to sustain something. So for example, for critical power testing, I would say again, also, when you first do critical power testing, it's more interesting to know, let's say, how fast, uh, or how far are you able to get over one minute, for example, five minute and 15 minute, and then actually see what happens in the next time you do it for the one minute, the five minute and 15 minute, because this is actually quite crucial to understand also the balance or what's happening with the different balances in, in the body. Uh, also FTP, uh, obviously there you have already most people, uh, think of this as, as a 20-minute power, so it's even a little bit more condensed or even simpler, uh, information. But, um, as we will probably come back to, is the, the balance when you're training, there are two things that normally can happen. One is that you, you, you increase your general capacity, meaning that both power and capacity, uh, or one or two are increased. Um, the other thing that happens there is that at some point we are all time limited, and this is where we need to pivot. So we need to pivot or as a prioritize what is more important for us. Is it the more explosive or speed, or is it more endurance? And then it's becomes more interesting for how you guide the trining, training to-
4. 14:58 – 24:35

   Lactate threshold: factors affecting it, testing protocols, & how efficiency affects performance & lactate profiles

   1. PAPeter Attia14:58

      we did a, um, a lactate protocol, a, um, a, a speed or power escalation, right? I think we talked about this on the last podcast, which was, you know, kinda the way we used to do it in swimming is you'd... I think we would do 200 yard swims.

   2. OBOlav Aleksander Bu15:14

      Mm-hmm.

   3. PAPeter Attia15:14

      So you do a 200 yard swim at a very modest pace, come back, check the lactate, rest, do it again five seconds faster per 200, go and do it again. Just lactate, da, da, da, da, da, and you get a plot, so pace on the, uh, x-axis, lactate on the y-axis, and the curve is very distinct, right? It, it is very, very flat, and then it is not. And you would-- we would draw these tangent lines between the two, and then that point was the lactate threshold. Um, where would that typically lie, assuming we did it on a bicycle, so it was really easy to do the power checks. Um, first of all, how long a duration would you have an athlete do this if you were doing it on a, on a, on an ergometer? Um, would you, would you say we're gonna do, you know, three minute efforts or something like that? Is that appro- is that appropriate to generate the lactate performance curve?

   4. OBOlav Aleksander Bu16:04

      It depends, again, how you're gonna utilize it. Uh, if you're gonna use it for actively, let's say, controlling the intensity outdoors, for example, using a lactate meter, I w- um, then, then I would say it really doesn't matter, because then you could say that-

   5. PAPeter Attia16:20

      Even taking into account that there's some lag between what's happening in the muscle and what's happening in the blood?

   6. OBOlav Aleksander Bu16:25

      Exactly, because the thing here is that here you're looking for more, let's say, um, not necessarily... Here also it's important just for me to say initially that when you find, for example, a lactate concentration of LT1 and LT2, for example, or basically AT and LT, for example, or AT, LT2, but we basically say lactate turn point two and lactate turn point one, so the first one and the second one. And then, uh, when you do this, it's also a misconception to think that your, your LT2 is always a constant value, because this will be in- influenced by many factors. We measure a concentration in the blood, and the blood, uh, i- or let's say not, uh, it's influenced by hydration and all things like this. So for example, if you have a change in hematocrit, and we won't come into that, but you can easily from the beginning of the session towards the end of the session see changes in hematocrit of more than 10%, and this will already-

   7. PAPeter Attia17:14

      As you get dehydrated.

   8. OBOlav Aleksander Bu17:15

      Yes.

   9. PAPeter Attia17:16

      Yep.

   10. OBOlav Aleksander Bu17:16

       Uh, so this will already influence, uh, the lactate concentration. But again, this is where you, to use it as a guiding principle, it really doesn't matter how long your steps are. If you, if you, basically what you're looking for is to find a concentration-

   11. PAPeter Attia17:27

       Interesting

   12. OBOlav Aleksander Bu17:27

       ... value, and then you go out into the field and you're trying to figure out where this is. So you are, you basically said, "Okay, uh, if you figured this out to be for an endurance," or let's say for sake of simplicity we say one millimole and two and a half millimole.

   13. PAPeter Attia17:40

       Yeah.

   14. OBOlav Aleksander Bu17:40

       So one millimole at, at the lactate threshold or LT1, and then two and a half at, uh, at, uh, LT2 or anaerobic threshold, AT.

   15. PAPeter Attia17:48

       By the way, I w- we usually saw them a little bit higher than that. We usually saw the, the... Actually, I didn't really differentiate between LT1 and LT2. I kind of looked at the single inflection point just using a two line. Um, usually people were kind of in the three to four range was where that inflection point. So that, you're saying that corresponds to LT2?

   16. OBOlav Aleksander Bu18:09

       Yes. So, and this also comes back to a little bit what kind of athlete you are.

   17. PAPeter Attia18:13

       Swim-- Yeah, this was mostly swimming that we were doing.

   18. OBOlav Aleksander Bu18:16

       Yeah. You can imagine here, uh, that, uh-

   19. PAPeter Attia18:18

       I found swimmers, by the way, had the highest lactate capacity.

   20. OBOlav Aleksander Bu18:22

       Where-- But, yeah, for, for basically for how much lactate-

   21. PAPeter Attia18:24

       How much lactate they would produce and tolerate. I don't know.

   22. OBOlav Aleksander Bu18:26

       And to- can tolerate, yeah.

   23. PAPeter Attia18:27

       Yeah. Why-- Any idea? Was that... I mean, it could be just a small sample size, but, um.

   24. OBOlav Aleksander Bu18:31

       Could. No, it, it, very often it depends on what kind of swimmers. If you look at a hundred meter swimmer, for example, then you would typically look at a swimmer that has a very, very short, uh, let's say, uh, duration.

   25. PAPeter Attia18:41

       I would say, so call it two to four hundred.

   26. OBOlav Aleksander Bu18:43

       Yeah.

   27. PAPeter Attia18:43

       Breaststroke, butterfly, individual medley. I don't think there was anything that ever... I n- I never saw higher numbers of lactate in myself or other swimmers than in those. I always assumed it was two things. It was individual medley, you're using every muscle in the body.

   28. OBOlav Aleksander Bu18:57

       Yeah.

   29. PAPeter Attia18:57

       So you just... It's not like cycling or running. You're hemorrhaging lactate into the system. Uh, and then secondly, at that distance, two to four hundred, I mean, you're really in the pain train of, you know, you're, you're, you're clearly not able to do this fully anaerobically, so you're sort of maximizing aerobic and then topping up anaerobic. But, but that was sort of why, um, I, I sort of assumed. I mean, literally I measured on s- several elite swimmers lactates over twenty millimole.

   30. OBOlav Aleksander Bu19:25

       Yeah. That's, that's probably not, uh... You-- I think very often it helps, uh, to think that metabolism is basically the same. There is no... Or the body is the same no matter what kind of sport we do.
5. 24:35 – 38:47

   VO2 max: definition, testing, factors affecting its accuracy, & methods for optimizing oxygen utilization

   1. PAPeter Attia24:35

      Yes. Yep.

   2. OBOlav Aleksander Bu24:35

      So utilization normally, just to take that term then, uh, or let's say partially, let's say take, define utilization. Utilization is basically normally you can do it as whatever you want. You can do it as a, as a race base, oxygen consumption at race base versus your VO2 max. But very often in scientific literature, we define this as, for example, your oxygen consumption at, uh, maximum lactate steady state versus VO2 max. So for example, if it, if it was, uh... Then it could be that your maximum lactate steady state, you see the oxygen co- uh, consumption there is, for example, 80% of your VO2 max.

   3. PAPeter Attia25:09

      Wow. Is that, is that what you would typically see in an elite athlete? That their max-

   4. OBOlav Aleksander Bu25:13

      That's low.

   5. PAPeter Attia25:13

      That's low.

   6. OBOlav Aleksander Bu25:14

      That's low. For a marathoner, you would go even higher. So for a marathoner, like the elite marathoners, you're talking about 94, 95% of their VO2 max. For Kristian, Gusta, when they do Ironmans, you're also pretty much around there. And again, also this is some of the things that I really enjoy. [laughs]

   7. PAPeter Attia25:29

      Sorry, let me get, let me just make sure we get people to understand that, because that is... As you know, now that I have a VO2 master-

   8. OBOlav Aleksander Bu25:35

      Mm-hmm

   9. PAPeter Attia25:35

      ... I'm testing my VO2 max all the time, and I'm also testing my VO2 at submax levels all the time as well, and looking at how that corresponds to lactate levels.

   10. OBOlav Aleksander Bu25:44

       Yes.

   11. PAPeter Attia25:44

       So, um, why don't you define VO2 max, and then we're gonna come back to this point, 'cause I wanna make sure people can internalize and maybe even one day experience what you just described.

   12. OBOlav Aleksander Bu25:57

       So V- VO2 max is normally defined as the maximum oxygen your body is able to consume, uh, over a minute, a full minute. Um, um, but this is also something that is debated. It's less of, let's say, protocol, uh, influenced, but it is still... You can still go out and do, for example, uh, efforts out in the field, and you will be able to produce higher numbers than what you would be able to do on a standard graded exercise protocol. So this is also a little bit of where it's, it's, it's not-

   13. PAPeter Attia26:34

       That's been the case for me.

   14. OBOlav Aleksander Bu26:35

       Yes.

   15. PAPeter Attia26:35

       Right? You know, I've shared with you my da- I've shared my data with you. So, um, my... I like to do it on my bike on a hill. So take a, take a hill-

   16. OBOlav Aleksander Bu26:44

       Good place

   17. PAPeter Attia26:45

       ... that's gonna be, you know, it's not too steep, 6% grade. You're in the saddle the whole time, and you're in the big chain ring, and it is go for broke, and make sure you're dead at the top. Four minutes of climbing, and that produces a VO2 max.

   18. OBOlav Aleksander Bu27:00

       Yep.

   19. PAPeter Attia27:00

       There's gonna be a level, usually near the very top of the hill in the last minute, where I reach the maximum volume of oxygen that I'm consuming. Now indoors, I for some reason hate doing it on a stationary bike, so instead I do it on a StairMaster. Um, so now I'm just sprinting upstairs doing the same thing. Um, I get a comparable number, but it's a little bit lower. Now, what I haven't done yet, and I was gonna try to do it before we met today, but I kind of ran out of time. I was traveling last weekend. I have a prediction, which is I think I would have a vi- a higher VO2 max running on a treadmill, even though I'm very inefficient running, because my heart rate is always higher when I run than when I cycle. Do you think that would be the case?

   20. OBOlav Aleksander Bu27:44

       [sighs] Normally, I would say, uh, that should be the case. Um, but it, i- it is also, um, where there can also be other factors also, uh, involved in it. Uh, like one of the places where, uh, this is something that have quite, uh, um, pissed me is that, for example, Formula 1 drivers-

   21. PAPeter Attia28:12

       Yeah

   22. OBOlav Aleksander Bu28:12

       ... they sit in for almost, let's say, one and a half hour-

   23. PAPeter Attia28:14

       Yep

   24. OBOlav Aleksander Bu28:14

       ... with extremely high heart rates. Um-

   25. PAPeter Attia28:18

       But having looked at that telemetry very closely-

   26. OBOlav Aleksander Bu28:21

       Yes

   27. PAPeter Attia28:21

       ... a lot of that is driven by the G-forces. It's... Because I've n- I mean, the first time I looked at an F1 driver's telemetry, I was like, "There's a mistake. These are just errors. Like, these aren't real numbers," because I had never seen such rapid changes from low to high to high to low. Um, and then I realized they were all corresponding to either very, very strong break points or very, very fast corners. And then I, you know, obviously the only thing that's common to that is something about 5G on the body is dramatically doing that. Now, it would be very interesting if we could do it [laughs] I don't know how you would do it, would be to measure VO2 and see if it has a commensurate change.

   28. OBOlav Aleksander Bu29:05

       Exactly.

   29. PAPeter Attia29:05

       What would you hypothesize?

   30. OBOlav Aleksander Bu29:06

       So this is, I think also, uh, when, when you are doing, uh, these kind... So it could also be, like, jet fighters as well, but, um, yeah.
6. 38:47 – 47:45

   Testing VO2 max: common mistakes & key factors to consider—preparation, warm-up, timing

   1. OBOlav Aleksander Bu38:47

      to. There will be some differences.

   2. PAPeter Attia38:48

      What are some of the mistakes you want people to look out for? Because again, people listening to this podcast are no stranger to VO2 max. We talk about it as an inc- you know, if you were gonna sort of say, "I need to know 10 parameters of my body for optimal health," VO2 max is on that list every day of the week.

   3. OBOlav Aleksander Bu39:04

      Yes.

   4. PAPeter Attia39:04

      So if e- even if you are listening to this and you don't care about triathlons or cycling or swimming, but you just have the desire to live as long as you can and as well as you can, you have to know your VO2 max, and you need to, uh, optimize it and make it, frankly, as high as you can with whatever time you're willing to devote to training. That said, most people aren't gonna go out and buy a VO2 Master, and they're not gonna, you know, geek out and do this stuff on their own. They're gonna rely on going to a place where the VO2 max is measured in a stationary fashion, either on a treadmill or on a bike. What are some things that those folks need to be aware of when they go to a center to test this as far as mistakes that people make? So for example, I've seen many people go and do a test, and I talk to them after, and I go, "How exhausted were you at the end of the test?" And they say, "Eh, I... It was okay. I could've kept going." And I'm realizing, "Okay, you didn't do a maximal test." Um, other mistakes I've seen are people who don't have a long enough warm-up time. You know, the t- the to- the total test took five minutes, and I'm like, "Well, you, you didn't, you didn't come close to sufficiently warming up." So are there any other things that you would just have people have in the back of their mind when they call a place up to say, "Hey, I wanna come and do a VO2 max test, but before I give you my hundred bucks, I wanna understand the protocol"?

   5. OBOlav Aleksander Bu40:12

      Yeah, and then, of course, the question becomes also to what extent you're able to, to influence this as well because there are some practices that they, they want it done in a very rigorous way. They even almost prescribe what you should do the days leading before and another where you just come in, and they, they just put you through-

   6. PAPeter Attia40:27

      Yeah

   7. OBOlav Aleksander Bu40:27

      ... a test, and then you get what you get.

   8. PAPeter Attia40:29

      So what should folks look for? What w- where-- If you were sending somebody to just a, a, a public place where they could go and do this, they're not coming into your lab where you're going to administer the test, um, what would you want them to be looking for?

   9. OBOlav Aleksander Bu40:42

      So, uh, what I would normally do is, uh, i- is, one, I would try to create, uh, some standardized protocol from time to time, and that means not only the testing itself, but also what happens a little bit before. Without it, it becomes too invasive into people's lives, like-

   10. PAPeter Attia40:57

       Mm

   11. OBOlav Aleksander Bu40:57

       ... standardizing what you do the days before and all these kind of things. I think this is impractical for most people.

   12. PAPeter Attia41:02

       Yeah.

   13. OBOlav Aleksander Bu41:02

       Like, if, if, if this is a very important metric for you, like, the me- or like one of the key metrics you use in order to understand how have the previous period influenced you and you're looking for marginal changes-

   14. PAPeter Attia41:14

       Yes

   15. OBOlav Aleksander Bu41:15

       ... then, then it becomes very important also how you standardize the days before. But I would say for a normal person, I would say that I would, uh, keep a standardized protocol for how... So I would come in there, let's say, at least trying to eat pretty much the same, uh, every time I go there, and that means, uh, that means making sure you are well fueled as if you were gonna do, uh, important training session. That means, um, normally more carbohydrates, make sure you're well hydrated, and obviously also that you are, um, to the extent you can influence it, or you can, you should be able to influence it, but make sure that you also had, uh, a proper sleep so you don't come in, like, completely tired and things like this.

   16. PAPeter Attia41:55

       Reasonably well rested.

   17. OBOlav Aleksander Bu41:57

       Yeah.

   18. PAPeter Attia41:57

       Maybe not train the day before, would you say, or light training the day before?

   19. OBOlav Aleksander Bu42:00

       I would say that as long... You know, I would-- This is where I would say more, it's more important to use your experience than to, to, to, uh, have enough understanding of what in or makes you set up for a good test the day after.

   20. PAPeter Attia42:12

       Yeah.

   21. OBOlav Aleksander Bu42:12

       So for some, some people, uh, that, uh, exercise is, uh, irregular and, and there are more time in between, obviously, if you're gonna do a little bit harder exercise the day before or anything like this, you'll come into the session, and you even f- you even feel sore in the muscles. This is not ideal necessarily for the ability to mobilize. Uh, for other athletes, uh, that are m- well-trained, then it's completely different. Then it's more like, okay, how-- what would I do the day before a competition or anything like this? Doesn't have to be an elite level.

   22. PAPeter Attia42:39

       Yeah.

   23. OBOlav Aleksander Bu42:39

       But more like you think a little bit like, "What do I want to do in order to, to make sure that I... I've gone through the different stuff, and I feel ready for the day after?" So on the day of the test itself, I would, I, I would... One is important, timing of the day. This is important to try to keep somewhat consistent, I would say-

   24. PAPeter Attia42:55

       Mm-hmm

   25. OBOlav Aleksander Bu42:55

       ... because of c- of the circadian rhythm. We know that, for example, your, your, uh, temperature levels in your body, this fluctuates. This is maybe one of the easiest observable differences in a human, basically as a, call it, as an indirect measure of the circadian r- rhythm, where we, we basically see that you have a minimum point that happens typically in the morning just before you wake up, and then you have a maximum point typically in the afternoon. And there is, of course, plenty of research suggesting that aerobic exercises are best done normally a little bit in the afternoon when you are typical also around the highest, uh, highest, uh, core temperature or natural core temperature. The minimum point is easy to measure, so for, for people that has the co-- like, like now it's become very popular, like in the Tour de France and other places, triathlons, you see these people, they run around with this little-

   26. PAPeter Attia43:43

       Temperature, yeah

   27. OBOlav Aleksander Bu43:43

       ... temperature me- uh, device on, on their, on their body. Um, uh, and it's very easy to observe if you use it 24/7. This is very easy to observe basically when your minimum point is. The maximum point is influence can... let's say, can be masked by noise and other thing, activities and other things you do, so it's a little bit harder to see where it is. But let's say you put them 12 hours apart as, as a, as a guiding tool. But now I'm already getting to the point where it gets a little bit, let's say, more detailed, but I would just say keep the timing of the day the same. So it really doesn't matter if you do it in the afternoon or you do it in the morning, as long as you keep it consistent. Uh, then, uh, from there I would do a proper warm-up. That's important.

   28. PAPeter Attia44:22

       And how long do you think that should be for, uh, uh, an untrained... for, for a person who's, like modestly trained? Let's assume we're not doing this on someone completely untrained, but someone who's, you know, recreationally trained versus relatively elite.

   29. OBOlav Aleksander Bu44:34

       So again, here I would, uh, y- do a warm-up much in the same way I would do a training session. So I would, I would normally stick to a standardized warm-up protocol where you start out maybe, for example, six minutes very easy. This can even be walking. Then I would do... or, or basically pedaling, soft pedaling. Then I would do six minutes with a little bit more effort, but it typical should be more something that you would be comfortable doing, uh, as your longest sessions that, that, that you do. So if you are out and you do, let's say the longest sessions you do is an hour, and obviously if they're all out then it would be a little bit too hard, but then you should more aim for something I could do for like this would be an easy session for me-

   30. PAPeter Attia45:08

       Mm-hmm
7. 47:45 – 57:33

   VO2 max measuring instruments, testing protocols, & advanced insights gained from elite athletes

   1. OBOlav Aleksander Bu47:45

      this is a good way to, to, to open up, uh, let's say a little bit the door to, to how we... wh- where we are because, again, we are at the edge cases where basically we don't have-- we have to do the research ourself. But one thing that you, what... one thing we have to consider is that basically when we do this kind of... when we do gas exchange measurements, for example, to understand a little bit the, uh, substrate metabolism-

   2. PAPeter Attia48:07

      And, and what's, what's your preferred in-lab test? Do you use Parvo or-

   3. OBOlav Aleksander Bu48:11

      No. We, we use a, a device which is, uh, it's an... actually a, um, still on a old device. There are two devices I like to use. One is the Jaeger Oxcon Pro with a mixing chamber, and this is important.

   4. PAPeter Attia48:23

      Yes.

   5. OBOlav Aleksander Bu48:24

      Yeah. Uh, the Parvo has a mixing chamber as well, but, but we have the Oxcon Jaeger Pro. Uh, when I've been testing in the US, for example, on elite athletes or Olympic athletes, then we have used the Parvo simply because that's the one that has been here. Europe is more used to Jaeger. Uh, we don't use the, uh... well, maybe I shouldn't say that we don't use the Vinto CPX, which is the successor of, of the Jaeger Oxcon Pro. Um, but, um, uh, this, this is, this is one of the devices. Uh, we use also the AEI Moxus, but this is more of a, call it, um, for specially interested people. Uh, and then we use the, we use also the VO2 Master actually quite significantly, and more and more of the testing actually have gone over to the VO2 Master. We have been fortunate enough to working with them for some while, so we have the C- the c- let's say the CO2 version as well.

   6. PAPeter Attia49:13

      Yep.

   7. OBOlav Aleksander Bu49:13

      But this is where it, uh, let's say it has been in alpha mode and it requires, um, also completely different skills than what you would normally require. But, um, the reason also why we do that is, again, also for one of the reasons you experience is that you see the VO, VO2 max is maybe a little bit different when you are out and cycling and do the efforts and it's not inside a laboratory. Because also we have to remember that VO2 max is, is o- on, on the one side we say it is the highest oxygen consumption over normally as, say, normalized over one minute.

   8. PAPeter Attia49:42

      Yep.

   9. OBOlav Aleksander Bu49:43

      We... that is a result of how much muscles that are involved in the work there. So obviously modality will influence this quite, quite a bit as well. So that's also why there is also

   10. PAPeter Attia49:53

       Which is why I was surprised when you said the guys were lower in swimming than cycling and running, even though I realize that their efficiency in swimming is relative to the world's best less than it is in cycling and running, where they would be closer to the world's elite. Um, but I would have just thought more muscles would have meant higher O2 consumption.

   11. OBOlav Aleksander Bu50:11

       Yeah, so, so actually let me shed some light on it because I said, uh, like I started with actually just on that one, that was basically when I started working with Kristian and Gustav. Where they are today is that basically there are virtually no difference between swimming, cycling and running. It's, it's, it's virtually

   12. PAPeter Attia50:24

       Same VO2 max

   13. OBOlav Aleksander Bu50:25

       ... more or less on the, on the three disciplines. But it has again to do exactly like you said, you can manipulate your VO2 max by that you're targeting, let's say typically shorter duration efforts and so you, you, you, you, you start recruiting more-- learn to recruit a little bit more and also train, uh, let's say fibers that you are not normally used to use so much and this is also something that is highly plastic, much more plastic than we ever have thought it was before, to the point where we, we have, uh, one of the-- we have, uh, yeah, we, we have some, um, leading researchers in, in Norway that have-- they've solely focused on VO2 max and let's say they, they went into schools where they've done this for decades. Uh, but where we even sat down and we looked at the data and thought something has to be wrong here. And that comes actually from the period when we switched from Tokyo, uh, Olympics and then on to Ironman, and basically we saw a decline in VO2 max. For me, not unexpected, but more like there hasn't been data on this, so it was actually quite nice to, to, to measure it.

   14. PAPeter Attia51:24

       And what was the decline? How much?

   15. OBOlav Aleksander Bu51:25

       So the decline, uh, in absolute or let's say in relative VO2 max, and so it makes more sense for people, is that Kristian and Gustav typically-- like the highest numbers we have had on them are, are very, very high. Um, highest numbers ever measured in history. But, um-

   16. PAPeter Attia51:40

       So, I mean, 90?

   17. OBOlav Aleksander Bu51:42

       Well, Kristian, uh, we've had measurements with him actually un- uh, unvalidated. Um, but on him, we, we, we have exceeded, um, in absolute terms seven point seven, seven point eight liters per minute in oxygen uptake. So-

   18. PAPeter Attia52:00

       At, at what, 75 kilos?

   19. OBOlav Aleksander Bu52:01

       Uh, no. So then he-- at that time, he was, uh, around 80 kilograms, so just let's say around, around, uh, 100 milliliter per minute per kilogram in oxygen uptake. Uh, so, uh, Gustav is a little bit smaller, so he has a little bit, let's say a little bit, uh, lower, uh, oxygen, oxygen uptake than, than, than what Kristian have. But he has typ- he has at the highest he's clocked in around, let's say 94 milliliter per minute per kilogram, something like this at the highest. But I would say that this is not beneficial for what they are doing.

   20. PAPeter Attia52:33

       Of course. Yeah, for d- a-again, I, I, I realize that just-- I mean, I, I think anybody who's done this type of testing and done this kind of work, it's, um, they'll have an appreciation for what those numbers mean, which is to say... I'm trying to come up with an analogy for another sport to explain what that would be. That would sort of be like-- [sighs] I just, I don't, I don't know how to compare it to non-endurance sports, right? Like it's-- I don't know. It's like, it's like, it's like saying, um, and in an NBA basketball game, occasionally they score 100 points. Like, it, it just doesn't... It, it's, it's, it's like... It doesn't, that doesn't compute. It doesn't, it doesn't really compute, um, that, that, that, that they could, that they could utilize that much oxygen.

   21. OBOlav Aleksander Bu53:17

       Yeah. So the interesting thing there, and the good thing about it, is that this was something we, we, we, we, we reproduced over three months.

   22. PAPeter Attia53:26

       But the training at that time was presumably geared specifically towards VO2 maximization. It was short distance, it was interval based.

   23. OBOlav Aleksander Bu53:34

       Well, actually, yes, it was. Uh, but this is also where, uh, one of the things that is that I, I-- one place I, I, I, I, I-- where we resonate a lot is that we both-- like VO2 max is the single best metric we probably have for anything that is related to human health and performance. Um, but it is a little bit more nuanced and it is also where we understand that it's a little bit more nuanced than that. And now I'm not talking about it as pure as a predictor for your race performance, because that's a different domain. But where you could also say that you could still be healthier with a little bit lower VO2 max. And I'm no- now I'm not talking because about that you put yourself through some stress and all things like this, so that's n- becomes negative longer term. But it ha-- but it's, it's-- VO2 max is a one-dimensional also unit again. We, we talk about something on a Y-axis. Yes, we normalize it as a milliliter per minute, so you could say that it has a, a second axis to it, an X-axis or time axis to it as well, but we don't say how long you can-

   24. PAPeter Attia54:33

       Over what duration.

   25. OBOlav Aleksander Bu54:34

       Yeah.

   26. PAPeter Attia54:34

       We don't get into capacity.

   27. OBOlav Aleksander Bu54:35

       Ex-exactly. And this means also that you can trade off some of your VO2 max. Uh, a-and, and I would say that the, the best, the very, very best predictor is capacity. Like capacity is maybe the single best one for everything. But the problem is that testing for, for capacity is such a brute force endeavor that it, it's, it's not practical. It, it, it is really not practical. That's why VO2 max is the most-- like I would say is the single best predictor of everything in a-- measured in a practical way. Uh, but for, for Kristian, what was really nice when we, when we did this, this is not only-- it was not only actually where we measured... And, and I can say that we are at the edge where there are things here we don't understand. Um, there are still things we are researching. And like you said introductory, I'm in the applied world. And in applied mo- world means basically, uh, much more experimentation and understanding what happens here with some individuals. My sample size doesn't come from the population, it comes from the sheer amount of data that I gather on these athletes. So it's not like a single VO2 max test, it is so many VO2 max tests that there's probably no s- other human in history where they have been through these testing protocols over time. And where we be-- where, where we can correlate it to also a range of other, uh, metrics as well, both, uh, uh, internally, but also external metrics. And that means that, for example, here to give-- to put this into context, the good thing is that when we do testing, I normally on- not only have Kristian into the lab, I have also minimum of, let's say, one or two athletes as well into the lab, and our protocols are quite extensive. So this is also one thing that you have-- we, we already talked about the protocols can have an influence on testing. And what you do before the protocol will have an influence on your VO2 max. That's exactly why we're discussing should you warm up or should you not warm up? Yes, you should, because it will normally give you, let's say, a better result-

   28. PAPeter Attia56:28

       Yeah

   29. OBOlav Aleksander Bu56:28

       ... when, when you are warmed up. But that means also that the protocol will also have-- can also then have an influence on your VO2 max measurements. And we normally do the VO2 max measurements at the end of our test, which is you would say, "Ah, but that's normal." Yes, well, we also do that simply because it also more normally simulates what they're also gonna see in on racing. So normally, what happens in racing is that you normally also will go closer to, let's say, complete exhaustion when you get towards the end of the race, and this is why it's interesting to test it there. But we don't only test it like once, we even repeat it. So we do two VO2 max tests just ten minutes apart, and even this year, we did even three tests, let's say with t- let's say with less than or ten minutes apart as well. Interesting thing here is that what we see is that you normally don't get your highest VO2 max on the first one even though you're exhausted. We even see that even on a, in a second one. More interestingly to also s-observe here is that then you would think that, let's say, intuitively you can say that, okay, uh, you would maybe also then see a higher carbon dioxide production as well. You don't. That's actually lowered. That has-

   30. PAPeter Attia57:29

       Hmm
8. 57:33 – 1:02:32

   The impact of beetroot concentrate & adaptogens on VO2 max & performance

   1. OBOlav Aleksander Bu57:33

      But also what we do see is that there are some substrates as well that actually do influence or micronutrients also that actually also are-- can help boost your VO2 max as well.

   2. PAPeter Attia57:42

      Such as?

   3. OBOlav Aleksander Bu57:43

      Long story short, uh, beetroots obviously have been like something that people have found quite interesting over a long time.

   4. PAPeter Attia57:50

      Beetroots?

   5. OBOlav Aleksander Bu57:50

      Beetroot, yeah.

   6. PAPeter Attia57:51

      Hmm.

   7. OBOlav Aleksander Bu57:52

      Uh, so they use beetroot concentrates and, and the main, let's say, thinking bet-be-- let's say behind this is that when you take-- when you, when you eat nitrate, so which beetroot is normally rich in, uh, and the body con-- let's say, uh, uh, converts this to n-uh, nitric o-oxide, this helps dil- also in, uh, for, for vasodilation.

   8. PAPeter Attia58:12

      Yeah.

   9. OBOlav Aleksander Bu58:12

      So, so vasodilation, you can think of this almost like a plumbing. So in our, in our body, we already said that from our pr-previous conversation that basically cellular respiration is not the limitation to your VO2 max. So there are other things that are limiting factor. Uh, w-- that means also that, for example, your cardiovascular, uh, system, meaning also actually your ability to transport blood around in your body is gonna be important. So the reason for why-- for example, one of the reasons for why, uh, when, when you then use, um, some, uh, supplements like, uh, uh, that con- that are highly enriched in nitrate, so you get a nitric oxide boost, is that this was actually-- it's almost like plumbing. You're opening up the plumbing and it allows-

   10. PAPeter Attia58:55

       Yeah

   11. OBOlav Aleksander Bu58:55

       ... your blood to blow-- to say, to, to circulate faster throughout your body. Uh, but one of the things that is this is hard to reproduce in elite athletes. Like in amateur athletes, we normally see that this has a positive effect.

   12. PAPeter Attia59:06

       How much of an effect?

   13. OBOlav Aleksander Bu59:09

       Oh, uh, then I have to go back and look a little bit on, on, on the studies that were-

   14. PAPeter Attia59:12

       But a real effect, like five percent, something measurable?

   15. OBOlav Aleksander Bu59:15

       Let-let's say something like that and then take that with a, with a grain of salt.

   16. PAPeter Attia59:17

       And this is a supplement. These are-

   17. OBOlav Aleksander Bu59:19

       Yes

   18. PAPeter Attia59:19

       ... these are not people that are out there literally eating endless beetroots you could buy as a supplement and-

   19. OBOlav Aleksander Bu59:24

       Yeah.

   20. PAPeter Attia59:24

       Yeah.

   21. OBOlav Aleksander Bu59:24

       Concentrate.

   22. PAPeter Attia59:24

       So now would it be anything that increases nitric oxide?

   23. OBOlav Aleksander Bu59:27

       So that's the thing, because one thing that we, w-we don't see this, we don't see these effects in, in, in, in elites, for example, and this is obv- obviously one of the benefits when we do a lo- more longitudinal studies with su-such, let's say, granularity and in-depth measurements we do. And one of the things we see there is that when they used, uh, because, uh, um, uh, beetroot concentrate or nitri- uh, nitrates are considered a ergogenic aid. Um, but when you do all these measurements, we, we leave out the guesswork and we see, well, over all the testing we do, we have not seen a real effect out of this, at least not on VO2 max. Maybe other places, but it doesn't seem to have any effect on VO2 max.

   24. PAPeter Attia1:00:10

       Because they're already optimized in that regard.

   25. OBOlav Aleksander Bu1:00:12

       Pro-probably. Probably. Maybe or maybe there are other limiting factors instead.

   26. PAPeter Attia1:00:15

       Mm-hmm.

   27. OBOlav Aleksander Bu1:00:16

       So then we, uh, we were approached by a company in, uh, uh, that is called Plasmid, and they actually focus more on the other part of it. Actually, the ca-- let's say the catalyst that actually, let's say, help because you have to convert nitrate into nitric oxide, and there's a cost to this. So what they did instead is that they made, um, uh, from pine bark extracts instead, they made a adaptogen or they extract an adaptogen that helps catalyze this process. And the interesting thing with this, uh, with this adaptogen is that w-again, now we are a place where we don't have-- we, we can just look at the observations and repeated observations over time, and we can't necessarily explain a hundred percent yet, so it becomes more speculations. But from those, what, what, what we can only speculate or, or hypothesize is that what happens here when they use this plasmid is that... I remember when we got this first presented, I was thinking like, "Okay, we, we, we, we've tested nitric oxide or nitrate. It really didn't give any help, so why should this really give a help or basically give any-- make a difference?" The interesting thing is that, uh, Kristian and Gustav were quite positive, so they say, "Okay, fine, we're gonna use this." We, we were just gonna test it. We had a bunch of them laying around there, and they say, "Okay, let's, let's try it." I thought, "Okay, fine." Uh, Kristian or Gustav was the first one to say immediately that he felt it did something with his respiration, but he couldn't... And then also it's a little bit the placebo as well of it. Like, okay, how much of this is placebo? How much of this is real? Like you get something new and say, "Oh, yeah, maybe," and you are looking for something in your body. And, and, and Kristian also, but he o-- he observed a little bit like a different effect to him. He felt more like he normally, uh, felt quicker ready for the next effort ... using this. But I would say that these record measurements that we did came in, let's say, in the, in the tail of when we started using this, and that was the little bit of shock because what we also saw at the same time was that the efficiency, so the biochemical efficiency in the body also went down. The c- the interesting thing was the RQ was heavily o- on the CO2 side was, was, uh, slightly, uh, reduced. The VO2 were heavily increased.

9. 1:02:32 – 1:13:48

   How respiratory quotient (RQ) reflects metabolic shifts during exercise, the challenges in measuring & interpreting RQ in elite athletes, & the physiological adaptations needed for prolonged endurance events

   1. PAPeter Attia1:02:32

      Tell folks what RQ is and what the reduction would imply.

   2. OBOlav Aleksander Bu1:02:35

      Um, yeah, I would say the-- we are talking of, let's say that, well, at the end, normally you would say that, uh, for a VO2 max test to be valid, like one of the criteria is that you should meet like one point one in RQ, so meaning basically-

   3. PAPeter Attia1:02:47

      Meaning you have ten percent more cons- production of CO2 than consumption of oxygen.

   4. OBOlav Aleksander Bu1:02:52

      Yes. In elite athletes, this is sometime hard. Like in the best trained elite athletes, bringing them to one point one during the test itself can actually be quite challenging. So if you have a short warm-up protocol, they are not well warmed up and all these kind of things, then you would be easily be able to exceed this. But if you do it more in a simulation like we did, or you have longer protocols before, you normally see that this is a little bit suppressed. So let's say that Kristian normally on a VO2 max test, or let's say at the end of the VO2 max effort, he would cl- he would, he would basically click in at, let's say, one oh five. Then after we started using these, uh, supplements, we could see suddenly not s- one oh three or one oh two. We basically dropped it by ten points, so basically to zero point nine five.

   5. PAPeter Attia1:03:33

      But preserving the VO2?

   6. OBOlav Aleksander Bu1:03:34

      No. So e- m- b- b- uh, V- CO2 was basically not as much changed.

   7. PAPeter Attia1:03:40

      So the VO2 was increasing?

   8. OBOlav Aleksander Bu1:03:41

      Yes.

   9. PAPeter Attia1:03:41

      Got it.

   10. OBOlav Aleksander Bu1:03:42

       So VO2 went up quite a bit. So first, obvious-

   11. PAPeter Attia1:03:44

       Mm.

   12. OBOlav Aleksander Bu1:03:44

       But the good thing here is that now I have two other athletes obviously in the lab at the same time, 'cause I have one athlete that comes in before Kristian, so I already do the dynamic calibration of the machines before. I-- we have a lung-- we also have a lung simulator just because we are working with edge, edge cases, so we need to independently validate the machines as well. So this means basically we have a large gas tank with a reference gas, and then you base in like beyond what is used for just the calibration. But we have a separate system where it basically we have a lung simulator where we feed in, for example, six liters of oxygen, six liter of CO2, and we know this is-

   13. PAPeter Attia1:04:15

       Yeah

   14. OBOlav Aleksander Bu1:04:15

       ... the exact amount in, in the bottle, gravimetrically calibrated. And then if we don't get this out of the machine, then, then, then there's something wrong with the machine independently of the calibration. But the good thing here is that, uh, despite this, first athlete in, numbers are where you expect them to be depend-- let's say based on the training we did before. Kristian comes in, basically we start to see some numbers that are crazy, and you start to be like, "Did I've, did I s- do something wrong here in the calibration process or anything like this?" But then also when you validate it afterwards, uh, as well, you basically know this is-

   15. PAPeter Attia1:04:44

       Mm

   16. OBOlav Aleksander Bu1:04:44

       ... the numbers are good. And then this we did then over a couple of, uh... We did this, this was in December, January, and February over nine tests, more or less. We s- saw a little bit over time that actually VO2 max started to come down a little bit because what this indicated also was that his biochemical efficiency was not optimal either.

   17. PAPeter Attia1:05:04

       Mm.

   18. OBOlav Aleksander Bu1:05:04

       What that means again is that if you look at basically his oxygen consumption versus his power, so, so the power, power was higher as well, but the ratio was not the same as it was before. VO2 had gone up much more than the power. Not... Well, yeah, well, well, enough.

   19. PAPeter Attia1:05:20

       Suggesting efficiency is going down.

   20. OBOlav Aleksander Bu1:05:22

       Yes, efficiency going down, and this was then, uh, eh... That means that, okay, so if efficiency go down, well, how c- can, can we somehow get an understanding of this? And this, of course, on this test, they actually are using a temperature pill. So we put a pill up their ass, uh, and also the same time, we have multiple, of course, sensors around on the body to also measure the temperature of the body as well, and where we basically see the same thing. We basically see an increased heat production for the same power output, basically indicating the same. You can basically think of like-

   21. PAPeter Attia1:05:52

       Yeah, I got it

   22. OBOlav Aleksander Bu1:05:52

       ... the reason why you have gas exchange is because we call this indirect calorimetry. Yeah.

   23. PAPeter Attia1:05:56

       So it's like it's not useful oxygen. It, your-- It's actually the worst thing you could possibly have 'cause you're also utilizing more fuel. So now you've created a scenario where for the same amount of power, not just you need more oxygen, oxygen is free, you're gonna need more glucose.

   24. OBOlav Aleksander Bu1:06:11

       Uh, well, actually not more glucose, but because since the, uh, since the RQ here is basically, uh, also now in favor, you actually are able to oxidize f- more fats.

   25. PAPeter Attia1:06:21

       Oh, that's interesting. Yeah. So you're saying because the RQ came in the same, you're gonna hold carbohydrate metabolism constant, and you're actually increasing fat oxidation.

   26. OBOlav Aleksander Bu1:06:32

       Yes.

   27. PAPeter Attia1:06:33

       And that works out perfectly in the stoichiometry?

   28. OBOlav Aleksander Bu1:06:36

       Um, pretty close.

   29. PAPeter Attia1:06:37

       It's counterintuitive.

   30. OBOlav Aleksander Bu1:06:38

       Well, well, yeah.
10. 1:13:48 – 1:18:15

    Triathlon training: maintaining elite performance across triathlon distances

    1. PAPeter Attia1:13:48

       Yeah, so, so, so let's talk about that now in the context of the Olympics, right? So, so w- you talk about an athlete like Christian or Gustav, where, in theory, they wanna be able to go between three distances, in theory: Olympic distance, half Ironman, Ironman.

    2. OBOlav Aleksander Bu1:14:03

       Yes.

    3. PAPeter Attia1:14:04

       Let's remind people what the distance is. Olympic is 1.5 kilometer swim, 40 kilometer bike, 10 kilometer run. Elites are doing this in an hour 45-ish?

    4. OBOlav Aleksander Bu1:14:16

       Yeah.

    5. PAPeter Attia1:14:16

       Okay. Half Ironman ... it, well, let's just do Ironman. 2.4 mile swim, so 4K swim

    6. OBOlav Aleksander Bu1:14:23

       3.8K, yep

    7. PAPeter Attia1:14:24

       Yep

    8. OBOlav Aleksander Bu1:14:24

       Swim, yep, yep

    9. PAPeter Attia1:14:25

       Yep. 112 bike, so 180K bike.

    10. OBOlav Aleksander Bu1:14:28

        Yep.

    11. PAPeter Attia1:14:28

        Marathon run, 42K.

    12. OBOlav Aleksander Bu1:14:30

        Yep.

    13. PAPeter Attia1:14:31

        The best in the world are doing this in seven-ish, seven and a half. What are they doing it in?

    14. OBOlav Aleksander Bu1:14:36

        Yeah, seven, seven, like in the r- r- Kristian is, uh, so actually the record holder still. He actually did it on his debut, and it still stands. Um, but, uh-

    15. PAPeter Attia1:14:47

        What was the time? Seven-

    16. OBOlav Aleksander Bu1:14:48

        S- then it was s- there was 7:21, uh, some-

    17. PAPeter Attia1:14:51

        Okay

    18. OBOlav Aleksander Bu1:14:51

        ... yeah

    19. PAPeter Attia1:14:51

        So s-

    20. OBOlav Aleksander Bu1:14:51

        Yeah

    21. PAPeter Attia1:14:51

        ... seven and a half to eight hours

    22. OBOlav Aleksander Bu1:14:52

        Yeah, yeah

    23. PAPeter Attia1:14:53

        And then Half Ironman is you take that, every one of those last distances and you cut it in half, so just under two kilometer swim, 90K bike, uh, and call it a 21K run.

    24. OBOlav Aleksander Bu1:15:02

        Yes

    25. PAPeter Attia1:15:02

        So roughly twice the Olympic distance in some regards, less in others. Um, and again, they're doing this in three and a half hours.

    26. OBOlav Aleksander Bu1:15:11

        Yep.

    27. PAPeter Attia1:15:11

        So these are three very different events. Is it possible to be elite in all of them?

    28. OBOlav Aleksander Bu1:15:18

        Uh, so this also, uh, this is also quite, quite interesting because, uh, one of the main differences I would say that differs them, us, let's say call them as, um, or compared to the specialists in the, in the sports, is actually not their metabolism. If you look at their, uh, VO2 max on running, cycling, and, uh, swimming, you will actually see that they are equally or higher than, than their peers in those sports.

    29. PAPeter Attia1:15:45

        Yes

    30. OBOlav Aleksander Bu1:15:45

        But their efficiency is not the same, and th- this comes m- probably most down to the fact that they have to do three different sports. You, you, you don't get the, the same time of just pure stimulus, mechanical stimulus from, from doing something and optimizing it because you have to change, and it also has some priorities also as well. You kinda like in, in running you could say you want to have, uh, you don't want to compromise on your leg stiffness at all. In cycling, this is a little bit more beneficial to do this, for example. So here you have to strike a balance between the three, which makes it very complex. But in, in swimming they are higher than the, than the highest VO2 max that are measured on, on elite swimmers in the world. But the difference is also I had the bronze medalist-
11. 1:18:15 – 1:33:33

    How reducing drag in swimming could revolutionize performance & the role of biofeedback tools across various endurance sports

    1. PAPeter Attia1:18:15

       my thesis on swimming. I think of all the main, of all the three big endurance sports, I feel like swimming has the most potential for radical change in performance based on drag avoidance, right? So, so all, all of these sports, but especially swimming and cycling, come down to propulsion versus drag. Running is less so because y- these speeds aren't high enough relative to air. Obviously swimming, just so people listening understand why I would say that, swimming is much slower than running, but the density of water is, what is it? 1,300 times that of air. So you don't need a high V squared to get a lot of drag just based on the density of the medium you're in, which is water. So in that sense, cycling and, um, and, and especially swimming really come down to this ability to avoid drag, right? And that's why in a time trial, you know, position matters so much on a bike, and how can you generate power even if you have to compromise your power there. So it's... I feel like in swimming there could be like a massive breakthrough if a technique emerged that reduced output or power or forward propulsion by 10% but reduced drag by 20%. You know what I mean? Like I, I just... A- again, I'm so far from the sport, I don't know. But like to me, I, I would really be curious as to that. Because again, remember, this happened in cycling in the '80s, where prior to that nobody was paying attention to bike position, and then Francesco Moser comes along in 1984, smashes the one-hour record with all this crazy aero equipment. And then of course you got into Boardman and all these guys getting into more and more crazy aero positions where their actual power went down relative to what they could have been in a, in a less kinked position. But of course their speed went up because the, the f- you know, the CDA goes down. And I just wonder, like do, do you ever think about that in swimming, which is like, is there, is there some major disruption where we just have this dramatic change in technique to have a bigger positive impact on frontal surface area than the negative effect it might have on propulsion?

    2. OBOlav Aleksander Bu1:20:18

       Yeah, so this, this then touches up on, let's say, uh, one of my favorite areas, and that's biofeedback In cycling, we have extremely good tools for biofeedback today. You have a power meter and you have a GPS. So just these two combined, for example-

    3. PAPeter Attia1:20:33

       Speed and power perfectly.

    4. OBOlav Aleksander Bu1:20:34

       Yes

    5. PAPeter Attia1:20:34

       Yep

    6. OBOlav Aleksander Bu1:20:34

       Like we, we talked about last time when you were out riding 200 watts constant-

    7. PAPeter Attia1:20:38

       Yep

    8. OBOlav Aleksander Bu1:20:38

       ... and basically you see you getting faster. So, uh, you, you have this direct biofeedback because you, as long as you ride enough, you will basically start to get a very good feeling for when you sit at a certain power and you start, do different things. Some you creep up, like, half a kilometer power or one. Like, for per- person, when they start cycling or they cycle a little bit, like, for them, they, they, they, it doesn't become interesting enough yet because there are other things that is basically more challenging for them to, to master. But for people that do a lot of biking, like yourself, it, it's, it's, it's, uh, it's where you exactly start to pay, let's say, attention to those, let's say, even half a kilometer per hour, maybe even you're getting below that as well, where you start to really pay attention to this. Um, and then over time, simply also because wind and other factors ma- makes a difference, too. Running, this is also a place where we have really good biofeedback tools. You have your watch, you are running, and you can have a look at it. And now we have also really good power meters in running as well.

    9. PAPeter Attia1:21:32

       How does that work?

    10. OBOlav Aleksander Bu1:21:32

        So most of these are... There are some of these power meters in running today that r- requires, some of them requires an insole, so you put basically an insole inside and they basically m- measure the forces that are-

    11. PAPeter Attia1:21:42

        So it's a force plate-

    12. OBOlav Aleksander Bu1:21:43

        Yes

    13. PAPeter Attia1:21:43

        ... inside your shoe.

    14. OBOlav Aleksander Bu1:21:43

        Yes. Yeah. And then you have other ones that are more motion capture devices, so they basically, you rather input your body weight, and since basically when you are touching on the ground with one foot, you are basically carrying your whole weight there. So as long as you have a good enough motion capture device that are capable of, let's say, detect or that are able to capture the three-dimensional accelerations, you can then basically also say some, well, you know, you know the force because you basically have to carry your weight. So that's how you-

    15. PAPeter Attia1:22:10

        So, but, so you can directly measure this with a force plate, um, insole, or you could indirectly do it with motion capture. But I assume the motion capture only works on a treadmill. You're not gonna be able to-

    16. OBOlav Aleksander Bu1:22:20

        No. So the motion captures today, they are become so small. They are basically a small device that you attach to your shoe, and they are-

    17. PAPeter Attia1:22:26

        Oh, wow

    18. OBOlav Aleksander Bu1:22:26

        ... when, when we validate these in the, in-

    19. PAPeter Attia1:22:27

        Are these commercially available products?

    20. OBOlav Aleksander Bu1:22:29

        Yes.

    21. PAPeter Attia1:22:29

        Both of these?

    22. OBOlav Aleksander Bu1:22:29

        Yes. So if you, if you me- if you, if you go to a laboratory and you basically test this, you will basically see that, uh... So we have been for a long time in working together with Stryd. Uh, I started working with them when they were in beta stage, and we've gone through there. But basically they are so accurate today that when you, when you, um, measure, uh, on an athlete-

    23. PAPeter Attia1:22:51

        First of all, do you have any idea how much you just ruined my wife's life?

    24. OBOlav Aleksander Bu1:22:54

        [laughs]

    25. PAPeter Attia1:22:54

        Like, do you have any i-

    26. OBOlav Aleksander Bu1:22:56

        Tell me. [laughs]

    27. PAPeter Attia1:22:56

        So how many minutes do you think after this podcast am I gonna be on my computer ordering these devices, jamming them on her shoes? You know, she, she's running the Boston Marathon next year.

    28. OBOlav Aleksander Bu1:23:07

        Yeah.

    29. PAPeter Attia1:23:07

        And, uh, I'm convinced she's actually gonna run it faster than she did her first Boston Marathon 20 years ago-

    30. OBOlav Aleksander Bu1:23:13

        Mm-hmm
12. 1:33:33 – 1:40:48

    Effort regulation using RPE, heart rate, & power output, & the role of lactate in cardiac & athletic efficiency

    1. OBOlav Aleksander Bu1:33:33

       Yeah. Yeah.

    2. PAPeter Attia1:33:33

       I, I guess in, in cycling, you know, one could ask the question, so when the guys are on the bike, are they paying more attention... So let's just talk about them doing a four-hour ride in an Ironman. Are they more concerned with... 'Cause you're triangulating between RPE, heart rate, and power. How are they prioritizing those things, how they feel, what the heart rate is, and what the power meter says? How are they regulating effort based on those things in a race?

    3. OBOlav Aleksander Bu1:34:01

       In training or racing?

    4. PAPeter Attia1:34:02

       Race.

    5. OBOlav Aleksander Bu1:34:02

       Oh, in racing I would say that then they only... Because then we use also other sensors as w- or let's say in training we use also many more sensors.

    6. PAPeter Attia1:34:10

       Okay.

    7. OBOlav Aleksander Bu1:34:10

       And then we limit it a little bit more in racing simply because it's not practical to-

    8. PAPeter Attia1:34:14

       Yeah

    9. OBOlav Aleksander Bu1:34:14

       ... to, to, to do it there. Um, but I would say that, uh, in, um, uh, this is also a very interesting topic because then it touch up a little bit more on psychology, but w- we'll come back to that ano- ano- ano- another time. Uh, uh, um, but, uh, in, in racing obviously first and foremost y- you, it's... Ironman racing is so long, it's so long, and with all this practice you know, let's say you shouldn't be, be slave to the numbers for sure.

    10. PAPeter Attia1:34:41

        Yeah.

    11. OBOlav Aleksander Bu1:34:42

        Because you can have suddenly your hero day where you're just able to, oh, go faster than what you normally do, so you need to listen to your body.

    12. PAPeter Attia1:34:47

        Yeah.

    13. OBOlav Aleksander Bu1:34:47

        So I would maybe say that RPE is the most, the, the most important one you could say in, in, in some, some senses, or RPE is also a place where you can also talk about one dimension, two dimensions be R- because RPE is normally, um, let's say if you take Kipchoge-

    14. PAPeter Attia1:35:02

        Yes

    15. OBOlav Aleksander Bu1:35:02

        ... when he, when he t- did a two, two-hour marathon, uh, or m- sub-two-hour marathon, uh, if you'd put him on a treadmill and you did a normal step test on him and you asked him when he was at 21 kilometer per hour and you ask him, "How does this feel?" He would say... So let's say that we, we, for the sake of the discussion we say that seven is around threshold-

    16. PAPeter Attia1:35:18

        Yeah

    17. OBOlav Aleksander Bu1:35:18

        ... our anaerobic threshold, something you could, let's say if you relate it to FTP, something you would be able to hold for around an hour-

    18. PAPeter Attia1:35:25

        Yeah

    19. OBOlav Aleksander Bu1:35:25

        ... for well-trained athletes. Or what you would test for when you did a 20 minute protocol and then you subtract the 5% to extrapolate it to that. If you asked him at 21 kilometer per hour, "Okay, how do you feel here?" And he gives you an RPE score, he would maybe say, "Ah, this feels like a six," when he was at 21 kilometer per hour or actually slightly above. If you ask him at the end of a marathon, "How do you feel?" And he's still running the same pace, he will say probably 10.

    20. PAPeter Attia1:35:46

        Yeah.

    21. OBOlav Aleksander Bu1:35:46

        This is a nine to a 10.

    22. PAPeter Attia1:35:47

        This is, this is all out.

    23. OBOlav Aleksander Bu1:35:48

        Because we forget again there is a-

    24. PAPeter Attia1:35:49

        The duration

    25. OBOlav Aleksander Bu1:35:49

        ... another dimension and that is the duration. Let's say the fatigue component that comes in there. And that's why it also helps sometimes to ask, I would say that you... When, when I ask my, when I ask Kristian Gustavsen at least-

    26. PAPeter Attia1:35:59

        But also his heart rate might be different there too. When you throw him on at, for a minute at 21 kph and he says RPE six, his heart rate's probably a lot lower than it would be two hours later at that pace, right?

    27. OBOlav Aleksander Bu1:36:12

        That's also... That, but that brings us back a little bit also to, uh, exactly, uh, utilization as well.

    28. PAPeter Attia1:36:18

        Mm-hmm.

    29. OBOlav Aleksander Bu1:36:18

        Because one of the things that you would probably not be able to do, you won't be able to get yourself up to a maximum heart rate at the end of a race even.

    30. PAPeter Attia1:36:25

        Yeah.
13. 1:40:48 – 1:50:24

    Lactate’s role as a fuel, buffering methods, & the variability in athlete response to bicarbonate supplementation

    1. OBOlav Aleksander Bu1:40:48

       lactate actually is very interesting in that const- in that context simply because it ex- it is extremely energy efficient, and that is, in the end, limitation for elite athletes.

    2. PAPeter Attia1:41:00

       How difficult to deliver orally? I assume it's delivered in a salt?

    3. OBOlav Aleksander Bu1:41:04

       Uh, well, uh, that is what we... This is actually something we started discussing, uh, because you could... The interesting thing of it is on, in a salt, is that it could also then, in that sense, has a little bit the same effect as bicarbonate. So you could use it as a, as, as a, as, as, as, as a buffer.

    4. PAPeter Attia1:41:22

       Y- yeah, let's make sure folks understand the, the, the, the, the chemistry there. So I was gonna actually ask you about this, and then I, we got off onto another topic. Is the... So I want to come back to that exact question, but we'll preface it with this question. People ask me all the time, "Hey, you know, I understand, Peter, that as I, my, my workload increases, my production of lactate increases, and as my production of lactate increases, my capacity starts to fall off because as lactate goes up, it's buffered by a hydrogen ion, uh, or it's, it's married to a hydrogen ion, and that's what creates the acid part of lactic acid. Um, and it's that hydrogen ion that's causing all the trouble. It's not the lactate. We can consume, we can tolerate endless amounts of lactate. We just can't tolerate-

    5. OBOlav Aleksander Bu1:42:06

       And lactate is crucial in metabolism.

    6. PAPeter Attia1:42:08

       Yeah.

    7. OBOlav Aleksander Bu1:42:08

       Yeah.

    8. PAPeter Attia1:42:09

       We just can't tolerate the hydrogen-

    9. OBOlav Aleksander Bu1:42:10

       Yeah

    10. PAPeter Attia1:42:10

        ... that comes with it, and it's that hydrogen that actually paralyzes the actin-myosin filaments, prevents them from disengaging, and that's what leads to that seizing up that you feel, the rigidity you feel when you're at, and when you exceed your lactate threshold. So the question then becomes, "Well, can I buffer this?" And everybody and their brother talks about, "Hey, what if we, you know, took lots of Tums, you know, anything that we get, could get sodium bicarbonate into our systems?" M- my looking at that literature, which I haven't done in a while, was that this, this strategy didn't really pan out, that the, the, there wasn't really a great way to orally ingest enough bicarb to make a difference. Obviously, intravenously you could, but that's probably illegal anyway. I mean, I don't think WADA would permit that. Um, but even if you weren't concerned with that and just asking the theoretical question, unless you're on a stationary bike, it's not practical to have an IV drip of bicarbonate to buffer your hydrogen. So what is the state of buffering agents to reduce and lessen the impact of, of, of lactid ac- lactic acidosis?

    11. OBOlav Aleksander Bu1:43:15

        Uh, so, so this is, uh, uh, it, this is a little bit of a complicated, uh, domain simply-

    12. PAPeter Attia1:43:22

        Unlike all the other simple domains we've been discussing today.

    13. OBOlav Aleksander Bu1:43:25

        Yeah, of course. [laughs]

    14. PAPeter Attia1:43:26

        Yes.

    15. OBOlav Aleksander Bu1:43:26

        No, the, the, the reason for that, uh, I've been very fortunate over the last decade to be involved in ex- like edge, a lot of edge case, uh, researches. Plenty that, uh, let's say w- we are maybe year, we are... Or not maybe, we are years away, uh, before this will be published, not necessarily because we don't want to publish in it, but, but there just remains work to be done-

    16. PAPeter Attia1:43:49

        Yep

    17. OBOlav Aleksander Bu1:43:49

        ... to understand it. And for example, again, this is also a place where, um, uh, where we have some indications now, but where some of my colleagues, they have actually also tested on larger population. But Gustav's highest VO2 max actually is done under bicarbonate, uh, utilization.

    18. PAPeter Attia1:44:11

        How?

    19. OBOlav Aleksander Bu1:44:11

        Not Kristian, but Gustav.

    20. PAPeter Attia1:44:13

        How? How is it administered?

    21. OBOlav Aleksander Bu1:44:14

        So, so the way it was administered is that, uh, there's a company in Sweden, uh, called Morton, uh, and, uh, what they did, uh, this is actually something that is gonna be studied now also in actually in, in health. Let's say, or less in medical settings as well, because it actually has some quite interesting, uh, applications there too. Um, but, uh, how this was administered is basically that it is packed in a hydrogel, and this allows you to byp-

    22. PAPeter Attia1:44:41

        Oh, so you get rid of the gastric p-- you would bypass the gastric pH, and you get it into the intestine

    23. OBOlav Aleksander Bu1:44:46

        medicine using the same mechanism. You basically pack your, uh, let's say, the, the, the, um, the agents into a vehicle-

    24. PAPeter Attia1:44:55

        Yeah

    25. OBOlav Aleksander Bu1:44:55

        ... to, to, to deliver it where you need it, uh, more efficiently. So this means that we can go to concentrations that are significant.

    26. PAPeter Attia1:45:04

        What have you seen is the difference in his lactate tolerance with and without this buffering?

    27. OBOlav Aleksander Bu1:45:10

        So this is a place, again, where obviously the sample size is still limited, um-

    28. PAPeter Attia1:45:15

        Sure, but in him.

    29. OBOlav Aleksander Bu1:45:16

        Yeah, yeah. Yeah

    30. PAPeter Attia1:45:16

        In, in, in a, in a super-- in a world-class elite athlete.
14. 1:50:24 – 1:55:34

    Mechanisms behind differences in performance between two elite athletes: lactate transport, cardiovascular efficiency, & compensatory systems

    1. OBOlav Aleksander Bu1:50:24

       can be completely different other places in the body.

    2. PAPeter Attia1:50:25

       So, so here's just a, a crazy idea. Have you ever done a muscle biopsy on the two of them to see the relative differences in monocarboxylate transport density on their muscles?

    3. OBOlav Aleksander Bu1:50:36

       No. That, that, that, that we haven't, that we haven't done. But I, I, but-

    4. PAPeter Attia1:50:40

       But, but think about this as, I mean, just for the-

    5. OBOlav Aleksander Bu1:50:41

       Yeah

    6. PAPeter Attia1:50:41

       ... listeners to understand what we're talking about, right? So the, so the, the MCT transporter on the muscle cell must play a significant role in determining the relationship between intracellular lactate and intraplasma lactate. And I, I, you know, it would be in an athlete's best interest through training to increase the density of those, because the more you can get lactate out of the cell, the more presumably you're gonna get the hydrogen with it out of the cell. We probably have a greater capacity to buffer lactate... Uh, pardon me, we probably have a br- a better capacity to buffer acid in the plasma because we have the respiratory drive to get, uh, to, to adjust bicarb than we do in the cell, where it's, you know, the, that hydrogen is really poisonous. So, you know, it just makes me wonder, as a hypothesis, maybe Kristian has more MCT density, and that's why he is less impacted by this buffering strategy. I don't know. I... Or it could be the other way around. Like, I, I just, I wonder if all things equal, that would be... It, it's just so hard to believe that two world-class athletes could be that different in their response.

    7. OBOlav Aleksander Bu1:51:48

       So I think, uh, one of them, one may be... So one can be MCT transporters, yeah, for sure. One can be. But I doubt it to be significant.

    8. PAPeter Attia1:51:57

       Yeah.

    9. OBOlav Aleksander Bu1:51:58

       Yeah.

    10. PAPeter Attia1:51:58

        It's hard to imagine that's 2X difference, right?

    11. OBOlav Aleksander Bu1:51:59

        Yeah, yeah. A- and the reason why I doubt that to be significant is because if I look at purely the biochemical efficiency, first order principle, looking at oxygen versus power output, m- gross mechanical power output, this is so close that it can't explain it alone.

    12. PAPeter Attia1:52:13

        Mm.

    13. OBOlav Aleksander Bu1:52:14

        One other difference that is there, and which is maybe larger, but I don't know, uh, uh, um, but it m- maybe are closer related to this is, for example, exactly plasma and blood volume. Because the blood volume and plasma volume in Kristian and Gustav is beyond significant in difference.

    14. PAPeter Attia1:52:36

        Why? They're not that different in weight, are they? 80 kilograms versus-

    15. OBOlav Aleksander Bu1:52:40

        But still it is, it is, it, it is borderline where the word significant doesn't do the word just-

    16. PAPeter Attia1:52:48

        Why?

    17. OBOlav Aleksander Bu1:52:48

        ... honor, then the difference. Again, also one of the places where we don't have any definitive answers. It is just different. But then you can say, "Well, wouldn't that have had implications on, for example, the VO2 max?" Like-

    18. PAPeter Attia1:52:59

        Like stroke volume.

    19. OBOlav Aleksander Bu1:53:00

        Yeah.

    20. PAPeter Attia1:53:00

        Cardiac output.

    21. OBOlav Aleksander Bu1:53:00

        Yeah.

    22. PAPeter Attia1:53:01

        The whole thing.

    23. OBOlav Aleksander Bu1:53:01

        Well, actually, that's the interesting thing, because if you talk about stroke volume, I would agree, yes, there is a massive difference. Again, significant doesn't really does, uh, do it justice. We would talk about massive differences in, in, in, in, in stroke volume, but not in cardiac output. The cardiac output-

    24. PAPeter Attia1:53:16

        What's the max heart rate of each?

    25. OBOlav Aleksander Bu1:53:18

        Uh, this one is, uh, so Kristian, uh, let's say ballpark-ish around 180 maybe, 170, 180. Uh, I don't remember ex- I, I would say 178.

    26. PAPeter Attia1:53:31

        Okay.

    27. OBOlav Aleksander Bu1:53:32

        Something like this. Gustav, uh, around 200.

    28. PAPeter Attia1:53:35

        Yeah.

    29. OBOlav Aleksander Bu1:53:35

        Yeah. So this is one, but also more interesting here as well is that Kristian has a much larger also hemoglobin mass than what Gustav have. But the, but one thing we also have to remember is that if you look at the... If you, if you create a performance stream, more or less, and we put VO2 max on the top of this one, where all these different factors are contributing, let's say, contributing factor to your VO2 max in the, in, in the end. That's why we say the VO2 max is, is the holy grail or, or such a good, um-

    30. PAPeter Attia1:54:05

        Yeah
15. 1:55:34 – 1:58:35

    Comparing interventions like acetaminophen to enhance performance in high-heat conditions versus natural adaptations to heat

    1. PAPeter Attia1:55:34

       Let's go back and say one thing about temperature. Um, there's some reasonable data suggesting that a relatively high dose of acetaminophen can certainly improve heat performance, so t- tolerance, you know, race pace tolerance in, in, in, in warm temperatures, that it may even perform output, right? And again, nobody knows why. Is it improving performance, i.e., absolute output, because it's actually reducing and blunting body temperature, and the temperature itself becomes a bit of a governing mechanism on output? Or if it's just blunting pain, and pain is part of the, uh, wall that we face. Um, but any... Curious if you have any experience with, you know, high doses, sort of 1 to 1.5 grams of acetaminophen in any of these athletes.

    2. OBOlav Aleksander Bu1:56:19

       No, we don't. We don't use it. And-

    3. PAPeter Attia1:56:21

       Have you experimented with it in training?

    4. OBOlav Aleksander Bu1:56:23

       No, no. Uh, one of the reasons why we don't do it is because, uh, I believe at the moment you start manipulating, you're trying to manip- And you can always say that they're, they're, like, what is not manipulating? Like, already when you're using exogenous, for example, uh-

    5. PAPeter Attia1:56:37

       Bicarb

    6. OBOlav Aleksander Bu1:56:38

       ... yeah, bicarb, carbohydrates for that sake, or anything like this, you can already say, "Okay, uh, well, this already also has an ef- uh, let's say, a, a, an effect." Um, but I would say that the problem when you try to go in and you try to acutely, let's say, um do something in the body. It means basically that you're trying to target one part or one system of the body, and you don't, you don't consider the other ones to be, uh, important. What I more believe in is that, for example, if you, if you talk about heat, for example, and heat tolerance, uh, if you have more of a natural appo- approach to this and you build this into your protocols, this means basically that, let's say, whatever is in the body that is there in order to help increase your heat tolerance have to ad- adapt to this. So for example, um, um, saying that pain is something that is trainable, for example, and there are many mechanisms that are involved with this. Um, I... the-- And using, using, for example, supplements to try to lower the pain, for example, or the perceived pain of something, I think this is-- it, it's a place where one... Talking about, for example, performance-enhancing drugs, it's interesting to see that, for example, despite, or let's say post, let's say, the big doping scandals there were in cycling, everybody thought that, okay, now time... the, the, the, the Tour de France will become slower.

    7. PAPeter Attia1:58:09

       Yep.

    8. OBOlav Aleksander Bu1:58:10

       Did, short period, and suddenly it just became faster, became faster, became faster. I don't think this is because people are doping more now than what they did before. There are probably some cases where people still do doping or they are really, like, venturing into the grayer, gray area. But obviously we have found techniques and other things that are more powerful than using performance-enhancing drugs to get to this

16. 1:58:35 – 2:08:26

    Advancements in nutrition science, changes in cyclist body composition, & fueling strategies for athletic performance & growth

    1. OBOlav Aleksander Bu1:58:35

       level.

    2. PAPeter Attia1:58:35

       I'll share two with you. I'm curious to your thoughts.

    3. OBOlav Aleksander Bu1:58:37

       Yeah.

    4. PAPeter Attia1:58:37

       Okay. So, um, we're gonna talk about nutrition in a minute. You already alluded to the fact that your, your athletes are routinely able to consume one hundred and sixty grams of carbohydrate per hour on the bike on what- whatever, during competition. You know, a hundred years ago when I was competing in anything, we kind of-- we were stuck at sixty. Like, it was really hard to get past sixty grams per hour. So for ultra distance things like I did, you, you know, it really became a bit of an energetics problem. You had to start figuring out ways to get fat in the, in the me- in the substance that you were consuming just to get the additional calories, even though you didn't really need fat 'cause you have enough of it. It's glucose you're limited by. Um, I very recently, literally the other day, asked Lance Armstrong, we were talking about something unrelated, and I said, "By the way, Lance, back in the Tour, how many grams of glucose were you consuming per hour?" You know what he said? He said, "We didn't even pay attention to it. We just ate when we were hungry."

    5. OBOlav Aleksander Bu1:59:47

       Yeah. Exactly. Okay. Yep.

    6. PAPeter Attia1:59:48

       Right? So like... A- and again, this is not saying that the only reason those guys were exceptional is because they were using blood products. No. They were using blood products, and they were exceptional, and they trained really hard, but their knowledge of nutrition was very pedestrian to what it is today. You know, th- as you know, if you wait till you're hungry to start fueling, you're not fueling in an optimal strategy at all. So that to me is one enormous advantage in the Peloton today. I think that nutrition science has evolved so much that, you know, what these guys can do... I, I've heard rumors that they can put down two hundred grams per hour, that they've trained themselves up to that level. I think a second interesting difference in the Tour today, and I'd love your point of view on this as well, I think people forget how big cyclists were twenty years ago relative to today. If you look at the GC contenders in, in, in the era of Lance Armstrong, right? If you, if you look at, I mean, uh, look at, you know, Jan Ullrich, uh, Ivan Basso, Lance himself, I mean, these were guys that weighed seventy kilos. Lance raced at s- you know, he'd start the Tour at seventy-four and finish at seventy-two kilos. Like, these are normal-sized human beings. If you look at the, the GC contenders today, these guys are fifty-eight kilos. I mean, they're very small. So in cycling, if we think about it as watts per kilo, it's not that they've gone up that much on watts. Their absolute wattage is significantly lower than what it was twenty years ago. They've just gone down so much on weight. So I, I'm, I'm wondering what you think about those two factors that are clearly stark differences between the world's best cyclists today and the world's best cyclists twenty years ago as, as a way to bridge the gap between the use of drugs then versus not today.

    7. OBOlav Aleksander Bu2:01:43

       Yeah. So there, there are also a couple of other interesting topics here as well, but, uh, but I, uh, I think, yeah, nutrition obviously. Fuel in, uh, speed out in other end. Like, it, it, it's, it's crucial. And it doesn't help if you, uh, try to do something with your view to make some of the things if you're running out of fuel. It doesn't help to install a larger engine in a car-

    8. PAPeter Attia2:02:05

       If you're running out of gas

    9. OBOlav Aleksander Bu2:02:06

       ... if basically your, if your tank is-

    10. PAPeter Attia2:02:07

        Yep.

    11. OBOlav Aleksander Bu2:02:07

        Yeah, exactly. So the, just I think one of the biggest differences is exactly like you point out, like the attention to nutrition today in, in the World Tour, for example, is in a completely different level than what it was a long time ago. Uh, and I know also over the last, just over the last five years, uh, this have also made like a big, big change as well. Like, people are trying to make-- Because there's large teams, so they're even trying to devise tools and, let's say, methods and other things that allows them to, let's say, scale this a little bit more. The benefit I have working with a couple of athletes is that we can go on a completely different level than what they can do again. So we, we can, we can even, like- We use metabolic measurements even out in the field to do snap measurements basically just to see what is happening and become extremely detailed in what we do. Even looking at basically post-exercise, even what's happening there post, uh, or pre- pre- pre- meals, post meals, what even happens with your resting metabolic rate, because even this changes throughout the day. And to keep up the consistency over time, you need to fuel accordingly.

    12. PAPeter Attia2:03:07

        Yeah.

    13. OBOlav Aleksander Bu2:03:08

        But coming back to the question, and that is that I think, one, nutrition, yes, this is probably one... let's say one of the main contributors to why... Or I would say of the two, this is the main contributor to why they are racing faster today than what they did, uh, 10 years ago-

    14. PAPeter Attia2:03:23

        20 years ago. Yeah

    15. OBOlav Aleksander Bu2:03:23

        ... even, or even five, 10 years ago. Um, I... Further, I would say that the watts per kilogram, this is a place where I feel that there will... we will see a change again. I think actually that the weight of athletes will start to go up again, but the reason for why we start to see this dip going there is because if we look at more trying to understand, like, why did we end up with the training programs we have done and so on, obviously, eh, it's a very empirical, uh, approach to it, practical approach, which very often is extremely good when it just gets enough time to evolve. But at the same time, also what haven't happened is that we have adopted our training, uh, our training strategies, uh, in, let's say, in intact with, let's say, the availability of information technologies, all things that helps us do better fueling. Because one thing we also do know is that in order for any growth to take place in the body, you need obviously oxygen. We already talked about that, but we use oxygen obviously as a proxy to understand metabolism. And metabolism, again, is also a function of growth. So when you do, when you do training over time, you're obviously trying to signal to your body you need more muscles, you, m- it to be more efficient in one or the other way. And if you now start to limit or you put a cap on, on, on, let's say, fueling in order to drive down your weight, this will also start to impair most likely growth, or let's say, ideal growth as well. You become-

    16. PAPeter Attia2:04:44

        Do we see this in triathletes? I mean, w- cycling's an interesting sport because you don't really get a benefit from weight reduction if you're a time trialist, for example. In fact, it's the opposite. You actually... It's watts more than watts per kilo that matters.

    17. OBOlav Aleksander Bu2:04:57

        Yeah.

    18. PAPeter Attia2:04:58

        But obviously, if you're in the Grand Tours, all three of which are basically built around climbing, watts per kilo is ultimately the metric. Now, we can debate whether you can get a more optimal watts per kilo at a slightly higher weight than a slightly lower weight, but, uh, you know, clearly you're not gonna see people winning a, a Grand Tour at 80 kilos or 75 kilos. I think those days are probably gone. But in triathlon, how much of an effort do these guys put into their weight?

    19. OBOlav Aleksander Bu2:05:28

        So this is actually one of the interesting things, because if you talk about watts per kilogram, Kristian actually his watts per kilogram have gone up with increasing his weight, and we are-

    20. PAPeter Attia2:05:36

        You said he's 80 kilos?

    21. OBOlav Aleksander Bu2:05:38

        80 kilograms, yeah.

    22. PAPeter Attia2:05:39

        And his FTP is?

    23. OBOlav Aleksander Bu2:05:40

        Uh, well, if I'm gonna convert it to FTP, it would be probably in the range of 400 and... Yeah, if I did him on a 20-minute test, probably, yeah, let's say for the sake of simplicity, 420 for something like this, probably if, if we tuned him. Like, if, if that-

    24. PAPeter Attia2:06:01

        Yeah

    25. OBOlav Aleksander Bu2:06:01

        ... if, if that was how we did testing and we started to standardize that-

    26. PAPeter Attia2:06:04

        Yeah

    27. OBOlav Aleksander Bu2:06:04

        ... pro- maybe even higher. I don't, I don't know. It's really hard to say because we don't do FTP testing.

    28. PAPeter Attia2:06:09

        Yeah.

    29. OBOlav Aleksander Bu2:06:09

        Um, but, uh-

    30. PAPeter Attia2:06:10

        What... And his power, his... Uh, what would be his average power in a, an Ironman for four hours?
17. 2:08:26 – 2:21:23

    Optimizing endurance performance with utilization of carbohydrates & ketones

    1. OBOlav Aleksander Bu2:08:26

       Yeah. But also here is, like, one thing that is there, because if you also use, let's say, um... For, for example, like, this is, this is, this is the wonder of the body. Like, one thing that happens obviously if you start to use a lot of carbohydrate, so you go to 160 grams, we, we even clocked in at the highest numbers, uh, we measured is, is, is in excess of 240 grams per hour of, of carbohydrate utilization.

    2. PAPeter Attia2:08:50

       That is so St- can you tell people what 240 grams of carbohydrates looks like if it were food?

    3. OBOlav Aleksander Bu2:08:57

       [laughs] Uh, let me think. Um-

    4. PAPeter Attia2:09:00

       Like, do it in pasta or something like that. Like, how much pasta is 240 grams of carbohydrate?

    5. OBOlav Aleksander Bu2:09:05

       No, it, I, I... To, to make it simple, it would be probably as you took pure gel and you filled this glass and you drank it. Pure gel.

    6. PAPeter Attia2:09:15

       Okay, so take those pure little nasty, disgusting energy gels, g- gels, and fill your 16-ounce glass there with it.

    7. OBOlav Aleksander Bu2:09:24

       And drink it.

    8. PAPeter Attia2:09:25

       Yeah, which, I mean, again, I, like... And, and, and what form are they consuming the, the, the carbohydrate in?

    9. OBOlav Aleksander Bu2:09:31

       Normally they would do it in the form of, of, of basically drink mix, so as, as a, they, they-

    10. PAPeter Attia2:09:35

        So how do they get that much liquid in their body?

    11. OBOlav Aleksander Bu2:09:38

        Uh, yeah, well, so that's a part of it. You, you basically, you take... Normally they would consume around, um, uh, I would say around minimum of 1.4 liters, but say around 2, a little bit more than 2 liters per hour.

    12. PAPeter Attia2:09:51

        Good Lord.

    13. OBOlav Aleksander Bu2:09:52

        So, so, but what they-

    14. PAPeter Attia2:09:53

        So what's the concen- what's the glucose concentration in that liquid?

    15. OBOlav Aleksander Bu2:09:55

        In, in that one, um, then I have to calculate.

    16. PAPeter Attia2:09:59

        So we could just do the math. If you said 2 liters, 200, that's 12%. That's a 12% mixture.

    17. OBOlav Aleksander Bu2:10:04

        Yeah.

    18. PAPeter Attia2:10:04

        Approximately.

    19. OBOlav Aleksander Bu2:10:05

        Probably, yeah, yeah.

    20. PAPeter Attia2:10:06

        Which again, that also completely flies in the face of traditional nutrition science, which says 5 to 6% is the limit for gastric tolerability and is the sweet spot for absorption, right? At 5 to 6%, your max... And now again, we're, that's a different problem. That's optimizing for water absorption into the cell, not your primary point. You're probably overdoing it on liquid, and you're trying to maximize glucose into the cell. But-

    21. OBOlav Aleksander Bu2:10:35

        But also absorption here is, because this is also where it's interesting or important then to go back to also a little bit like, what is this research? Like, who is this research done on as well?

    22. PAPeter Attia2:10:43

        Yeah, and it's not done-

    23. OBOlav Aleksander Bu2:10:44

        Yeah

    24. PAPeter Attia2:10:44

        ... on these trained athletes.

    25. OBOlav Aleksander Bu2:10:45

        Yeah, yeah.

    26. PAPeter Attia2:10:45

        Yeah.

    27. OBOlav Aleksander Bu2:10:45

        Yeah.

    28. PAPeter Attia2:10:46

        So, okay, first question, how long did it take you to train the athletes to be able to tolerate that? Because if, if someone's listening to us today and they're saying, "Oh, I heard, I heard, I heard these guys talking about the 12%, uh, carbohydrate concentration," uh, which again, just means for people listening, that means 120 grams of glucose per liter. That's twice the standard what you'd see in an energy drink. Um, and then I'm gonna drink 2 liters of that every hour. Uh, I think within two hours a normal person is gonna be puking their guts out. Like, they simply can't get that volume of glucose out of the upper, um, gastrointestinal tract. So is this, is this just like any other muscle where you can train yourself to exceed capacity?

    29. OBOlav Aleksander Bu2:11:33

        Seems like it. Seems like most things in our body is actually extremely trainable if you, if you, if you really s- And that, that also comes back to the nutrition part as well, where exactly also the training programs we have today also is very m- ha- have not seen the same change as nutrition strategies have done over the last years as well. So that means also that the power numbers that was output maybe five, 10, 20 years ago, I'm not so sure if that's the limitation we're gonna see.

    30. PAPeter Attia2:11:59

        Especially late in races, right?
18. 2:21:23 – 2:31:10

    Insights gained from elite Olympians

    1. PAPeter Attia2:21:23

       uh, re- remind me, did Kristian and Gustav both compete in Tokyo Olympics?

    2. OBOlav Aleksander Bu2:21:28

       No. Uh, yeah, both did compete in Tokyo Olympics, yes.

    3. PAPeter Attia2:21:31

       And, and how did they do in Tokyo?

    4. OBOlav Aleksander Bu2:21:32

       Uh, Kristian won.

    5. PAPeter Attia2:21:34

       Mm-hmm.

    6. OBOlav Aleksander Bu2:21:34

       Uh, Gustav came seventh, eighth.

    7. PAPeter Attia2:21:39

       Okay.

    8. OBOlav Aleksander Bu2:21:39

       Seventh, seventh place, yeah.

    9. PAPeter Attia2:21:41

       And then they, after that Olympics, they went back to Ironman distance for the next three years.

    10. OBOlav Aleksander Bu2:21:46

        Yep.

    11. PAPeter Attia2:21:46

        And then Gustav did not compete in Paris.

    12. OBOlav Aleksander Bu2:21:48

        Nope.

    13. PAPeter Attia2:21:48

        He had an injury. Kristian did, and I think you said he was 12th, correct?

    14. OBOlav Aleksander Bu2:21:53

        Yes.

    15. PAPeter Attia2:21:53

        Um, and how much of that was the mismatch in distance? Again, he's much more optimized for Ironman. Olympic distance is, you know, that's like asking a marathon runner to go and run a 5K. Very unusual. Um, what was the process like to get ready for that, and what was the difference in his personal performance between 2024 and 2021?

    16. OBOlav Aleksander Bu2:22:18

        So, uh, uh, to... Uh, I think, uh, obviously, uh, we, we went there because for two reasons. One, we, we, we thought it was possible to get back on the podium, and I would say even, uh, let's say even after disappointing results, I would say that we are more convinced today that it's possible to go back than we were. But there are other reasons for that to come back in, coming back to that.

    17. PAPeter Attia2:22:40

        Sorry, meaning in Los Angeles, you're saying?

    18. OBOlav Aleksander Bu2:22:42

        Yeah, no, no-

    19. PAPeter Attia2:22:43

        You're writing off on the-

    20. OBOlav Aleksander Bu2:22:44

        ... even in, in Paris, yeah. Even there.

    21. PAPeter Attia2:22:45

        Yeah, yeah.

    22. OBOlav Aleksander Bu2:22:45

        Yeah, yeah. So i- if we then look also back to there, Kristian already had in training put out far better performances than what he was capable of getting out on race day. Uh, I would say that there are two things that looking back at, uh, let's say the process leading into, uh, Paris that, uh, um, that r- for me explains most of, most of this. And one part of it is we, one of the differences leading from, let's say from Rio leading into Tokyo, was that we took a massive shift in how we did intensity control. And again, now we talk about intensity control, that doesn't mean necessarily about talking about just threshold, anything like that. This means exactly like pinpointing different intensities and, and working on them in order to optimize the human body.

    23. PAPeter Attia2:23:32

        Mm.

    24. OBOlav Aleksander Bu2:23:33

        And then how we fig- how we find this. One thing that we did, uh, actually we, we got maybe a little bit too, let's say complacent, complacent the last year, and that is basically we have done this so much that it's more like, okay, we, we had more projects, so it's also one place you just think, "Okay, you are, you are getting really good at controlling the intensity," and these kind of things. So w- we, we s- we s- we stressed it a little bit. So the, the key that really made a difference between Rio to Tokyo, we became sloppy at the last year leading into-

    25. PAPeter Attia2:24:03

        Rio to Tokyo or Tokyo to Paris?

    26. OBOlav Aleksander Bu2:24:04

        No, so f- so from, yeah, from Rio to Tokyo, we, we, we... That was a massive shift from basically-

    27. PAPeter Attia2:24:09

        Yeah

    28. OBOlav Aleksander Bu2:24:09

        ... becoming, let's say from going from unknown to-

    29. PAPeter Attia2:24:11

        Yes

    30. OBOlav Aleksander Bu2:24:11

        ... to basically Olympic champion, to basically where we, the last year, uh, I would say in particular, let's say the two, let's say last year, we were much more sloppy on, simply because you think that, okay, after you've done intensity control for so long time, you would think that you have such a good calibrated body for this, that this is... We made the same error actually already in 2017 to 2018, where 2016 to '17 we saw massive improvements in performance. From '17 to '18, we have done so much measurement, we lacked in other things like this. Just thinking, "Okay, they, they, they must have a good feeling for this, really good calibrated." To a couple of months, we saw that, okay, this doesn't work, we have to go back to the practice. The same error we did the last year going to Paris. Purely in terms of performance, Kristian basically put out performances that was far exceeding what he did on the run, uh, in, in To- in, in, you know, in, in Paris. In Paris, he lacked around four minute per kilometer over the 10K. That was, that was the difference between the first place and the 12th place.

Episode duration: 2:41:04