Exercise: longevity-focused training, goal setting, improving deficiencies (AMA 55 sneak peek)

1. 0:00 – 0:08

   Intro

   1. PADr. Peter Attia0:00

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

2. 0:08 – 2:02

   Overview of exercise topics

   1. SPSpeaker0:10

      Peter, welcome to another AMA. How you doing?

   2. PADr. Peter Attia0:13

      Very well.

   3. SPSpeaker0:14

      I think we're gonna get right into it because we got kind of a big one today. So with it being the new year, we know a lot of people are gonna start to either take their exercise more seriously, start to exercise, thinking of switching up their exercise routines, and we see so many questions around exercise come through. We thought this would be a good time to make it kind of an all exercise AMA. And some of the questions we see from people are, you know, they're wondering how to improve their cardiorespiratory fitness, how to increase their muscle mass, their strength, oftentimes how to do both. And so we pulled questions that are gonna look at how you solve these problems with clients in your practice. And this includes first really identifying and clearly defining what the goal of training is, because as you often talk about, if you don't clearly identify the goal, you don't really know what to do. And then from there, helping people understand how they can identify the area in their life that they need the most help in when it comes to exercise. And then we'll start to get into more technical questions on how people can use periodization training, how they can make improvements in areas that are most needed, and we're even gonna look at some case studies of what a different weekly workout could look like for a few different types of people. From there, we're then gonna step back and also look at some training questions that apply to everyone, no matter what level of expertise they're at. This includes how stress can impact a workout, and also how people should look at wearables and the data from wearables as it relates to making decisions on training. So we got a lot. So with all that said, anything you wanna add before we get into it?

   4. PADr. Peter Attia1:56

      No, I like your ambition, man.

   5. SPSpeaker1:59

      We'll see what we can do.

   6. PADr. Peter Attia2:00

      [laughs]

   7. SPSpeaker2:01

      Um,

3. 2:02 – 11:06

   Importance of training with a goal in mind, the Centenarian Decathlon, and the natural decline of fitness with age

   1. SPSpeaker2:02

      I think we first need to start a reminder for people on how you look at training and the goal of training. Because for you, you're not training to run a marathon, be a powerlifter. Instead, you're training for something else. And you've talked about this before, but I think it is important to just kinda lay that foundation for people so they know why you're making the recommendations, why you're doing what you're doing. So do you wanna remind people quickly what the Centenarian Decathlon is and why you use that as your training goal?

   2. PADr. Peter Attia2:33

      Yeah. So a- as you said a second ago, I am no longer an athlete. I don't train for anything specifically. Um, in fact, very recently, you know how your phone will pop up pictures of something that occurred, like, you know, this time five years ago or whatever. Well, uh, it popped up a picture of me from, uh, t-2014, and it was, uh, after a training session. This is back when we lived in San Diego. You remember where, uh, Fiesta Island is, Nick?

   3. SPSpeaker2:59

      Oh, yeah. Awesome.

   4. PADr. Peter Attia3:00

      Yeah. So Fiesta Island is where we used to train for the time trials, and it was a picture of me and Meb after a training session. So M-Meb was running, I was riding, and I look at the picture there. I'm in my, my kit, holding, you know, arm around Meb, and it's like, you know, he probably weighs a hundred and thirty-eight pounds. I weigh, like, a hundred and sixty-eight pounds, um, you know, twenty-five pounds or whatever less than I am today. And, um, you know, there's just no comparison to, you know, what I was then versus what I am today. Um, and I, I trained, you know, three times more than I train today in volume, and it was very specific. And, um, I've talked about this, but again, I think it's worth reiterating. When I stopped competing, when I was done with cycling, done with swimming, done with, you know, going, you know, being competitive a- at some level, um, I needed to find another goal because of what you said in the intro, which is you... It's very difficult to train without a purpose. And, um, I, I talk about this in the book, but I really had an epiphany in the summer of 2018. So I, I kind of had an aimless three years where I was exercising and I was reasonably fit, but I... There was no purpose. It wasn't anchored to anything. And it-- this all came sort of, I don't know, in a, in a, in a, in a flash of inspiration as I was sitting at the funeral, um, of, of the parent of a close friend of mine, realizing that in the last decade of this person's life who had died, uh, they were, you know, largely debilitated physically. Um, and that was tragic to me because I had seen them be healthy in their sixties and seventies. So that's what gave me this idea of we need a goal and we need to treat life just as we would treat an athletic event. And this idea of a Centenarian Decathlon came to my mind in part because decathletes are generally regarded as the best overall athletes despite not being the best in any one of the ten things that they do. Now, of course, Centenarian Decathlon is not an actual event. Maybe some people will do decathlons when they're centenarians. Um, but even becoming a centenarian is not necessarily the objective, right? We don't have that much control over how we stretch our genes. That said, what I imagine is in the last decade of my life, what do I wanna be able to do, and how do I begin to train for that now? And when you take that look at the future and you say, "Look, these are the things I wanna be able to do," you can apply metrics to those activities. You can say, "Hey, if I wanna be able to hike on uneven surfaces to the tune of, you know, two mile round trip in an hour, um, that requires this much cardiorespiratory fitness, this much strength, this much balance." And I know how much each of those things will decline over the next decades. So how much stronger do I need to be at fifty than I would expect to be at eighty-five or ninety? Um, there's a, there's a figure I pulled here, if you could pull it up, Nick. I think it's, um, it, it's a bit of a messy figure and, but, but the message is very clear. This is a figure that shows, um, on the, on the left it shows, uh, women, and on the right it shows men. The bottom two figures show physical activity level over time, so age is always shown on the x-axis. And the upper figure shows fat-free mass in kilograms on the y-axis versus, again, age on the x-axis. So fat-free mass, of course, is a very good proxy for lean mass or muscle mass. And you can see that these have data collected all the way from when people are teenagers up until the end of life. And again, you don't really have to be a statistician to see the remarkable trends here. So there's some obvious differences between men and women. The most notable one of just the difference in lean mass. Men have significantly more lean mass than women. But if you put that aside, you'll realize two things. The first is that we have a steady increase in muscle mass and lean mass, both for men and women, that occurs from birth right up until about the age of twenty-five. And then you have a relatively minor decline in lean mass from twenty-five to seventy-five. But then what happens at seventy-five, Nick?

   5. SPSpeaker7:38

      Yeah, it's off a cliff.

   6. PADr. Peter Attia7:40

      It literally falls off a cliff. Now, we do the same exercise for, um, physical activity. By the exercise, [chuckles] no pun intended, meaning you do the same, uh, visual exercise. You watch that from the ages of, uh, twenty-five to seventy-five, physical activity level is even more consistent and conserved than lean mass in both men and women. And yet, what happens at the age of seventy-five for both men and women?

   7. SPSpeaker8:13

      Yeah, same thing.

   8. PADr. Peter Attia8:14

      Yeah, it just falls off a cliff. Now, of course, this figure cannot give us causality. I can't look at this figure and tell you that the reason physical activity level falls off a cliff at seventy-five is because muscle mass does the same. Nor can I tell you that muscle mass is declining because physical activity goes down. But it's hard for me to imagine that what's happening here is not, um, bidirectional. In other words, I suspect that what's happening is that at seventy-five or thereabouts for the average person, activity declines, and as activity declines, muscle mass declines, and as muscle mass declines, activity declines further, and these things spiral out of control. And remember, the, you know, average life expectancy is about eighty, so that means that, you know, for people who are living to average life expectancy and slightly beyond, they're basically going to spend the last five to ten years of their life in a very poor physical state. And if there's anything that I hope people take away from the stuff that, you know, we've been talking about, it's that you must focus on healthspan at least as much as you focus on lifespan. And if there's an enormous failure in Medicine 2.0, it's the myopic focus on lifespan at the complete exclusion of healthspan. So with that rant sort of over, um, therein lies kind of the why. It, it really doesn't matter, you know, what, you know, what your athletic background is. Maybe you were a stud athlete growing up. Maybe you've never played a sport in your life, and you've never done so much as run a local 5K. Doesn't matter. Everyone needs to be an athlete for life, and therefore everyone needs to think about becoming the best version of their centenarian decathlete.

   9. SPSpeaker10:15

      And remind me, what was the furthest you've ever swam?

   10. PADr. Peter Attia10:21

       Furthest in one shot I've ever swam is about twenty-eight miles.

   11. SPSpeaker10:25

       So looking back at that picture of you and Meb, you know, would you say you were the better athlete and had more athletic achievements than Meb, or do you think it's not quite that clear?

   12. PADr. Peter Attia10:37

       [laughs] Meb, having won the Boston Marathon, uh, having won the New York Marathon, probably the most decorated, uh, American marathoner. I'm gonna give the slight nod to Meb on that. [chuckles]

   13. SPSpeaker10:51

       Y- you did bike around Fiesta Island a lot, though, so you have that going for you.

   14. PADr. Peter Attia10:55

       I, I, I was probably a better swimmer than Meb. That, that... Maybe I can take that. I'm sure if you put Meb on a bike, he would have ridden circles around me.

   15. SPSpeaker11:03

       Oh, yeah. Dude's just a machine.

4. 11:06 – 20:35

   The four pillars of exercise

   1. SPSpeaker11:06

      Um, so with that said, I think then we also need to quickly remind people of what you call the four pillars of exercise, which is if you agree that this is what you're gonna train for, which is ultimately life and life as you age and being able to do what you wanna do, and sometimes people, I think, can get lost in the very specifics of like, "Okay, I need to be able to do exactly this or exactly this." But even stepping back, for most people just acknowledging, "If I'm gonna focus on when I'm eighty, ninety, I want to be able to move freely, take care of myself," you know, just the large things, that can sometimes people give, give people the goal they need. And so with that said, do you wanna quickly remind people on what those four pillars of exercise are that anyone who has that goal is going to need to have all four?

   2. PADr. Peter Attia11:57

      Y- yeah. And, and again, I, I just wanna make sure people understand. For the Centenarian Decathlon, we're really thinking about things that are activities of daily living and activities of, of leisure and pleasure and sport and, you know, beyond activities of daily living. So w- we kind of encourage people in our practice to go through this exercise and make sure they have both of those in there. Um, now to your point, um, I think broadly speaking, the way internally we talk about this is four pillars, and this is the way I wrote about it in, in, in the book, right? So it's kind of two cardio pillars and two sort of strengthy pillars, and the cardio pillars are zone 2 efficiency, so this is aerobic effici- efficiency or maximum aerobic efficiency, and then peak aerobic output. So that's measured by VO2 max, whereas aerobic efficiency is measured, measured by zone 2 output. And then on the other side, we have strength, and within strength there's a lot, so we'll go into some more detail about what that means 'cause strength involves both, you know, muscle quality and motor control, and you have eccentric strength, and you have concentric strength and all those things. And then you have this other idea that wraps around strength called stability. And of course, stability speaks about the safety with which you can apply that strength, i.e. exert force on the outside world, uh, and the safety with which the outside world can exert force on you. And of course, inherent within stability are other issues that we think about, especially things that decline as we age, such as mobility, balance, flexibility.

   3. SPSpeaker13:42

      Looking deeper into those four, what are people able to track and kind of identify further to know where they're at? Which one of those are... Do people have the ability to kind of, as you said, you know, in strength, there's different aspects of it. Maybe just touch on what those aspects are so people know how they can start to measure in their own life where they're at and where they need help.

   4. PADr. Peter Attia14:06

      Yeah, there are so many, right? So, so let's take strength as an example. Um, so within strength, we want to think about, you know, peak strength. We want to think... So, so that would be kind of maximum, um, strength. Um, again, to be clear, that would be what is your maximum one rep max for something. We would wanna think about muscular endurance, so the ability to move something that's much lighter, but for many, many reps. Um, and it's important to point out, by the way, that you don't have to train at a one rep max to increase your strength, and you don't have to actually measure at that level. In other words, you could, you could see how much you could do something for five reps, and that would allow you to impute or estimate what you could do for one rep. And if you're a powerlifter who's competing in a sport where you have to do that, of course, that would be insufficient. But for, for those of us that are not powerlifters, you know, knowing what we could do for, you know, our best five reps is a good enough proxy for then, you know, calculating what our one rep max would look like. We then talk about various things like motor control. So, um, again, I think this is sort of a hybrid of the strength stability piece, but this is a really important, uh, you know... I, I gave the example of hiking over an uneven surface. You know, I just got back from, you know, a hunting trip a little while ago, and boy, you're, you know, you're walking around in the dark carrying heavy stuff on obviously uneven surfaces. Um, and that's a much more complicated and dynamic situation than, you know, riding a stationary bike, for example. So we wanna be able to train in both of those ranges. You wanna be able to train, um, under perfect conditions such as, you know, using a machine or, you know, being on a bike or something like that, and then you also wanna be able to train on variable surfaces and in situations where you have less control. And again, when we talked about cardio respiratory fitness, lots of things that we measure here, but again, you know, thinking of these in the two extremes, whi- which is what is the maximum output you can sustain while still exclusively utilizing, uh, your aerobic system? So therefore, you're not at all accumulating lactate. Um, a- and again, I'm being a lit- a little bit, um, uh, sloppy in my terminology there, and we can maybe clear that up a bit, a bit later, but, but basically, you know, what's the maximum output you can sustain without accumulating net lactate? Um, and at the other end of that spectrum, what is the maximum utilization you have of oxygen, which corresponds, of course, not to your maximum output, but more importantly, your maximum aerobic output. Again, these are very quantifiable, um, and as you know, these are numbers that we know for all of our patients, and I think they're numbers that everybody should know for themselves.

   5. SPSpeaker17:01

      Yeah, and I think that's a great lead into kind of the next place, which is you have the cardio respiratory side, you have the strength side. A lot of people are gonna be wondering, "Okay, how do I know where exactly I'm at in each of those so I can help identify if one or the other needs help or if they both need help?" So maybe walk through how people can understand their current state as it relates to those two things.

   6. PADr. Peter Attia17:29

      Thank you for listening to today's sneak peek AMA episode of The Drive. If you're interested in hearing the complete version of this AMA, you'll want to become a premium member. It's extremely important to me to provide all of this content without relying on paid ads. To do this, our work is made entirely possible by our members, and in return, we offer exclusive member-only content and benefits above and beyond what is available for free. So if you want to take your knowledge of this space to the next level, it's our goal to ensure members get back much more than the price of the subscription. Premium membership includes several benefits. First, comprehensive podcast show notes that detail every topic, paper, person, and thing that we discuss in each episode. And the word on the street is nobody's show notes rival ours. Second, monthly Ask Me Anything or AMA episodes. These episodes are comprised of detailed responses to subscriber questions, typically focused on a single topic, and are designed to offer a great deal of clarity and detail on topics of special interest to our members. You'll also get access to the show notes for these episodes, of course. Third, delivery of our premium newsletter, which is put together by our dedicated team of research analysts. This newsletter covers a wide range of topics related to longevity and provides much more detail than our free weekly newsletter. Fourth, access to our private podcast feed that provides you with access to every episode, including AMAs, Sans the Spiel you're listening to now, and in your regular podcast feed. Fifth, the Qualies, an additional member only podcast we put together that serves as a highlight reel featuring the best excerpts from previous episodes of The Drive. This is a great way to catch up on previous episodes without having to go back and listen to each one of them. And finally, other benefits that are added along the way. If you want to learn more and access these member only benefits, you can head over to peterattiamd.com/subscribe. You can also find me on YouTube, Instagram, and Twitter, all with the handle PeterAttiaMD. You can also leave us a review on Apple Podcasts or whatever podcast player you use. This podcast is for general informational purposes only and does not constitute the practice of medicine, nursing, or other professional healthcare services, including the giving of medical advice. No doctor-patient relationship is formed. The use of this information and the materials linked to this podcast is at the user's own risk. The content on this podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Users should not disregard or delay in obtaining medical advice from any medical condition they have, and they should seek the assistance of their healthcare professionals for any such conditions. Finally, I take all conflicts of interest very seriously. For all of my disclosures and the companies I invest in or advise, please visit peterattiamd.com/about where I keep an up to date and active list of all disclosures. [outro music]

Episode duration: 20:35