Fasting, well-balanced diets, alcohol, exercise, assessing cardiovascular health (AMA 68 Sneak Peek)

1. 0:00 – 1:08

   Intro

   1. SPSpeaker0:00

      First question, how does someone assess their cardiovascular health?

   2. PAPeter Attia0:05

      Family history, very important. Another thing that I think gets so overlooked but is so important is blood pressure.

   3. SPSpeaker0:11

      Anytime we've done anything around alcohol, it seems very polarizing, let's say.

   4. PAPeter Attia0:16

      Under no dose, helpful. Under low dose is probably not terribly bad, uh, but under escalating doses it, it's actually quite negative.

   5. SPSpeaker0:23

      Benefits and potential downsides of a low carb or ketogenic diet.

   6. PAPeter Attia0:29

      And there's nothing magical about not eating carbohydrates that's gonna be good for you. It all still ultimately comes down to total caloric ingestion.

   7. SPSpeaker0:37

      What do you think are the key principles for a, quote-unquote, "well-balanced, healthy diet?"

   8. PAPeter Attia0:43

      If you ask 10 diet gurus, I, I think it's safe to say you're gonna get 10 different answers.

   9. SPSpeaker0:49

      How can they track their fitness level beyond just weight?

   10. PAPeter Attia0:53

       When it comes to actual fitness, you know, we're not gonna get that off the scale. [upbeat music] Hey, everyone, welcome to the Drive Podcast. I'm your host, Peter Attia.

2. 1:08 – 2:53

   Episode format: overview of common health topics based on listener questions

   1. SPSpeaker1:09

      Peter, welcome to another AMA. How you doing?

   2. PAPeter Attia1:12

      Good. Thanks for having me.

   3. SPSpeaker1:13

      Always welcome on your own show.

   4. PAPeter Attia1:15

      [laughs]

   5. SPSpeaker1:15

      Uh, so today what we're gonna do is we actually have gathered all the questions over the past three or so years that people have submitted on the AMA portal. For people who don't know, we have an AMA portal on our website where you can submit a question. So if anyone hasn't done it, we'll link to it in the show notes, and that way if there's questions you have that you want follow-up on, whether it's something related to something that happened to you, questions on podcasts, newsletters, whatever it may be, you can add them there. And so that's kind of what today's AMA is gonna be. And we'll hit different diseases, we'll hit nutrition, we'll hit exercise. We'll kind of hit a little bit of everything, 'cause as people can imagine, questions came through included a little bit of everything. So I think we'll just jump into it. But with that being said, anything you want to add before we start with the first question?

   6. PAPeter Attia2:07

      Well, I think the only thing I would add is th- you know, we talked about maybe if this format, which is kind of more questions, less depth, um, more of, you know, how I would sort of answer questions if I were, you know, at a party and people were asking me. Um, if people want more of this, but on a personal level, uh, we've talked about, you know, accommodating that. So maybe we just do, you know, a quarterly episode where I take very specific questions from individuals. If they want to be acknowledged, do so, um, and, and, you know, do that. So anyway, I think there's just a lot we can play with in this format, so let's just see if folks, uh, find this, uh, helpful.

   7. SPSpeaker2:51

      Yeah. Perfect.

3. 2:53 – 9:20

   How to accurately assess your cardiovascular health

   1. SPSpeaker2:53

      First question, how does someone assess their cardiovascular health? It's obviously a topic that we've covered in such a variety of podcasts. Very important. You've often talked about number one cause of death, not only in the US, but in the world. And so kind of in general terms of someone sitting there thinking, "Okay, I'm curious about where I'm at cardiovascular and as it relates to cardiovascular disease," how would you talk to them about how they can assess where they're at?

   2. PAPeter Attia3:19

      So fortunately, if somebody wants to assess their risk of cardiovascular disease, it's-- we have a lot of tools to do it, right? We always start with the obvious, which is often neglected, but we should really know our family history. Um, it's not enough to just know, you know, my grandparents lived till such and such an age, or my aunt and uncles lived to such and such an age. Whenever possible, you really want to understand how grandparents, parents, aunts, and uncles, uh, lived and died. You know, and, and sometimes it's easier to ask questions like, "Hey, did they take medication or do they take medication for cholesterol, for blood pressure?" Um, and understanding those things. Again, some of the patterns that tend to show up here when you see people perishing really young from cardiovascular disease or when you see them requiring procedures such as revascularization, stents, CABG, things of that nature, uh, especially at a young age, you have to be thinking about heritable causes of ASCVD. And again, the two most common are going to be L- LP little a and some form of familial hypercholesterolemia. Now, the latter is a lot easier to spot because these people have sky-high cholesterol levels. The former is much more difficult because virtually nobody is getting their LP little a tested, and so that's sometimes the individual who themselves is, is kind of interested in assessing their own risk is the first to figure it out, and then it kind of explains what has happened over generations. So, uh, you know, family history, very important. Um, then you can sort of think about understanding, hey, has there been any damage done to date? And here's where a calcium scan, uh, or a CAC can be a very helpful test. Now, it's not a foolproof test. It has its limitations. But if you think about the process by which, um, damage occurs inside an artery, one of the final stages of that is the calcification of the artery, which actually is a protective mechanism. So the, the calcification of the artery per se isn't necessarily the thing that's going to kill a person, but it's indicative of very advanced disease. And if you see calcification in one part of an artery, it's quite likely that you have less, uh, remodeled plaque elsewhere in the, in the coronary artery system and, and in fact, those could be the ones that are at higher risk. So again, a calcium score in an ideal world is zero, but it's always important to remember that there's about a fifteen percent false negative, uh, meaning, uh, somebody ends up with a negative CTA, uh, pardon me, uh, CAC, calcium score zero. But in fact, if you were to put them into a CT angiogram, which uses finer cuts of a CT and uses contrast after it does the initial calcium score, you'll see in fifteen percent of those cases that there is indeed some calcification and/or some soft plaque. So, um, again, that's one more piece of information, and again, if you want to go to a level above the CAC, then the CTA is valuable. But now you're experiencing more radiation, and you also run the risk, um, of requiring, uh, intravenous dye or contrast, which again, is not a major risk, but it's, it's non-zero Um, the other things I really think a person can do to assess their risk of cardiovascular disease is, uh, obviously look at the lipid profile, right? So the two things we care most about here are ApoB and LP little a, and the reason for that, of course, is ApoB is the aggregate marker of, uh, all of the atherogenic proteins. Uh, because LP little a is so disproportionately atherogenic, um, you have to look at it separately because even an elevated LP little a won't show up elevating in ApoB. The good news is that you don't have to concern yourselves with LDL cholesterol, non-HDL cholesterol, HDL cholesterol. None of those things actually matter once you know the ApoB and the LP little a. In fact, the triglyceride level itself doesn't matter unless it's, uh, dramatically elevated sort of north of about four hundred milligrams per deciliter, at which point you would actually need to manage that as well. Um, another thing that I think gets so overlooked but is so important is blood pressure, and it's, it's just too easy to sort of go to the doctor once every two years, get your blood pressure checked, have it come back slightly elevated, have it be attributed to white coat hypertension, and then just sort of walk away from it. But the, the truth of the matter is we know pretty unambiguously at this point that having a blood pressure below one twenty over eighty is absolutely the lowest, uh, risk and is the best way to reduce one's risk. And to be clear, that means that a blood pressure of one thirty over eighty-five, which historically would have been considered normal, is anything but normal. Now, the challenge with measuring blood pressure in the doctor's office is it's almost rarely done correctly. Correctly means sitting there for five minutes, doing nothing, resting before the blood pressure is checked. It also means having a cuff that fits correctly, having the arm at the level of the right atrium, so about mid-chest here, uh, not having your legs crossed when it's checked, and I always like to check it in duplicate or triplicate. And, uh, if a person can do that twice a day for a couple of weeks, once a year, again, not a huge inconvenience in my view, then they can have a real assessment of their blood pressure. The other thing, of course, that's, you know, worth stating just for completeness, though I think everybody understands it, is smoking. If you're a smoker, you're at enormous increased risk of, uh, CVD, and of course, the same is true if you're metabolically unhealthy. This can be anything from hyperinsulinemia all the way to insulin resistance and type 2 diabetes. So those are really the big ones. There's a couple things I didn't include there. I don't really look at CIMTs. I don't find them to be helpful enough, and I think the data would agree with that. Um, so I think that's, that's probably eighty percent of risk assessment for cardiovascular disease is captured in what I just said.

   3. SPSpeaker9:09

      Yeah, and if anyone wants to go deeper on any of that, as we said, we have tons of different materials, podcasts, newsletters. We'll link them in the show notes for people who want to dive deeper on any specific piece of

4. 9:20 – 14:16

   The impact of fasting, time-restricted eating, and dietary restriction on metabolic health

   1. SPSpeaker9:20

      that. But next question that get asked-- that gets asked a lot is, "How can I use fasting or intermittent fasting to improve my overall metabolic health?" And I think a lot of times people use those two terms, fasting, intermittent fasting, interchangeably. And I know to you, you kind of think of them a little separately. So it might be helpful to start with how you define those two terms before then getting into how each of them can impact metabolic health.

   2. PAPeter Attia9:48

      Yeah. I think the terms fasting and intermittent fasting get used interchangeably. I, I'm not gonna represent that I'm the authority on any of this stuff. So I'm just going to tell you that whatever you are talking about, just make sure the semantics are clear so that you can normalize to what other people are saying. I typically don't use the term intermittent fasting. I use the term fasting, and I use the term time-restricted feeding or time-restricted eating to describe what I think most people think of when they say intermittent fasting. But as a general rule, intermittent fasting or time-restricted feeding or time-restricted eating refers to periods of not eating during the course of a day. So when you hear people say, "I do, you know, sixteen/eight or eighteen/six intermittent fasting," of course, what they mean is, "I'll go sixteen hours a day without eating, eight hours a day of eating, or eighteen hours without and six hours with." Fasting is a term I kind of reserve for prolonged fasts, anything that's more than a day, and this'll easily be two, three days, uh, up to, you know, really, really long fasts like seven, ten, or even fourteen days. Then again, the term fasting implies that it's water only, right? It's non-caloric. So whatever liquids you're getting during that period of time don't contain any calories. So now let's answer the question, how can you use fasting or time-restricted feeding or intermittent fasting to improve metabolic health? Well, I think the data here are not particularly clear. Um, so I'll start with the least clear of them all, which is the use of daily, uh, restrictions or intermittent fasting, time-restricted feeding. Uh, the, the data here suggests that this type of feeding pattern is no better than straight caloric restriction. In other words, when you normalize a person for the number of calories they consume during a day, whether they consume those calories across the course of the day or whether they consume those calories in kind of a small feeding window doesn't appear to have a material difference. What does matter if a person is interested in improving their metabolic health is that they restrict calories. And if you recall, I kind of talk about this always through the lens of three tools that we have to reduce calories. The first is the direct way that you go about doing it. You literally just go about counting and reducing the number of calories you consume. Again, this is the most precise way to do it. Um, This is why bodybuilders do it, right? Bodybuilders are-- You're not gonna find a person on this planet that is more attuned to, um, exactly what they put in their body and how that fuel gets partitioned. And so again, if, if you, if you want an exact science, you go about counting every calorie and macro that goes in, um, and, and you try to create that offset in that way. Again, for many people, this is-- this brings a lot of overhead with it, right? This is-- This, this brings a huge cognitive tax. Uh, and so we have two other techniques that can work quite well, um, indirectly. So the first is what we've just been talking about, intermittent fasting or time-restricted feeding, where you just say, "Look, I don't really wanna pay attention to, to, to what I eat or even how much I eat. But if I just make the feeding window narrow enough, that has got to reduce the calories." And indeed, it can. Not always. Uh, there's always the story of that person who, in four hours a day of eating, still manages to eat, you know, three thousand calories. But for the most part, as you restrict your feeding window, you're going to also reduce total calories. Then the third way to go about doing this is call-- something called dietary restriction, which says, "Hey, I'm not gonna con-concern myself with necessarily how much I eat. I'm not gonna concern myself with when I eat, but I'm going to put in some pretty significant restrictions around what I eat." And again, the more restrictive you are, the more you're gonna end up reducing calories. So I think the most important point to remember here is it's the calorie restriction that provides the greatest benefit. How you go about achieving it is really a function of, you know, your style. And I, I actually recommend people try all of these techniques. And, and, you know, we've, we've covered them in so much detail elsewhere and the ins and outs of what the pros and cons of each are because there are many pros and cons of each. Um, I think I dedicate a pretty significant section of one of the chapters in Outlive to covering this.

   3. SPSpeaker14:15

      Next question

5. 14:16 – 25:26

   Alcohol: health risks of consumption, limitations of research, and how to weigh the risks against social and personal enjoyment

   1. SPSpeaker14:16

      on the list relates to alcohol, and it seems like anytime we've done anything around alcohol, it seems very polarizing, let's say. There's a lot of opinions, strong opinions on each side. And so I think the general question is: How does alcohol affect someone's health or longevity, and how do you think about it?

   2. PAPeter Attia14:38

      I mean, there's no denying that alcohol affects our health. Alcohol is a nutrient like any other, but it comes with some particular issues that are a little bit unique to alcohol in a way that we wouldn't say are unique to carbohydrates, fats, and proteins, and that basically is the following. Alcohol, in addition to being a dense source of energy... You know, carbohydrates and proteins come with four kilocalories approximately per gram, and fats are at about nine, uh, kilocalories per gram, while alcohol is actually much closer to fats. It's at about seven kilocalories per gram. But when we're really talking about the impact of alcohol on health, we're not even really talking about it from its caloric standpoint, although I can tell you, having done more food logs with more patients than I can count, it is always amazing to see a patient's face when they recognize that twenty-five percent of their total calories come from alcohol if they're a moderate to heavy drinker. So you don't wanna be dismissive of the calories, but I think for this question, Nick, I'm gonna just put aside the caloric load o-of alcohol. So what we're really talking about is the toxicity that comes from the molecule itself n-nominally through its metabolism, um, uh, v- in, in the liver and sort of its metabolic byproducts. Now, we have a bit of a problem when trying to study this, which is we have to rely very, very heavily on epidemiology. And epidemiology is, of course, you know, one of many tools we have to understand the impact of environmental, um, in this case, potentially toxins on health, but it just comes with so much baggage. Now, again, when you're talking about an environmental toxin that is really, really toxic, like tobacco, epidemiology turns out to be an awesome tool because the hazard ratios are so big that it's impossible for there to be other explanations. The problem is when you're dealing with alcohol, the hazard ratios are quite small. This is basically true of all food, and this is why epidemiology just, you know, doesn't serve as a great substitute for randomized control trials when it comes to understanding these things. The problem is we don't really have great RCTs around alcohol, and the ones that we have are very short-lived. Now, we did an entire AMA on alcohol. We have an entire premium newsletter on alcohol, so I'm not gonna try to rehash all of that. So I just wanna kinda give the top-level stuff, right? So when you're doing these studies, one of the things you, you quickly come to realize is, um, people who abstain from alcohol for a reason, which is often where people are abstaining from alcohol, they're either former drinkers, um, or, uh, they have health reasons that prevent them from drinking. It-- There's often this paradoxical increase in mortality that we see. So if you, if you kinda look at some of the larger studies here, um, and the largest one, uh, that, that I've seen is the recent one that came out in JAMA last year. It included a hundred and seven cohort studies and nearly five million lives were studied, and it compared a bunch of different entities to lifelong abstainers. Um, so, you know, usually these are people who, uh, often have religious affiliations or, or other reasons to have never consumed alcohol. Now, when you compare former drinkers, so people who do not drink at all but who used to drink, they have about a twenty-six percent increase in all-cause mortality compared to lifetime abstainers. And again, that's kind of in keeping with what I said earlier, right? Which is these are people who used to drink. They don't drink now. There's usually a reason for that. Now, interestingly, when you look at, um, you know, the occasional, the low volume, and the medium volume drinkers, they actually didn't have an increase in all-cause mortality. And just to put some numbers to that, occasional drinkers basically don't drink at all. These are people that are averaging, uh, less than a drink a week. Um, the low volume drinkers are gonna be up to a drink and a half per day. Uh, although that's-- I wouldn't call that low volume, but that's how they were classified in that study. Then the medium volume drinkers were up to three drinks per day. Again, I-- if that's medium volume, I need to recalibrate. Um, but once you start to get into the high volume drinkers, uh, these are people that are drinking three to four drinks per day, and then the highest volume drinkers are over four drinks per day. These people start to see an uptick in their all-cause mortality at twenty and thirty-five percent, uh, uh, respectively, uh, relative to the, uh, people who abstain. Now, if you look at these data, um, and divide them by sex, you see another thing emerge, which is that, uh, across the board, women fare worse with respect to alcohol than men. So, you know, the, the first and most obvious explanation for this is simply body weight, right? So if you, if you sort of said like, you know, women who consume forty-five grams of ethanol per day versus men who consume forty-five grams of ethanol per day, of course, the women should do worse. Um, and I do think that body weight, and in particular lean mass, 'cause remember, lean mass is where we see water, and that's gonna aid with the metabolism of, of ethanol, um, that's, that's a part of it. But we also know that women contain less, um, uh, alcohol dehydrogenase, which is an enzyme that's responsible for the metabolism of alcohol. And the thinking, at least, is that if women have less alcohol dehy-dehydrogenase, just genetically, um, then they're gonna be more susceptible to the downsides of alcohol. So, um, a-again, I think there's a lot more we could say about this, but you know, the, the, the truth of the matter is, when you look across the board, alcohol is associated with at least three disease states: cardiovascular disease, dementia, and cancer, in addition to what I just talked about, which is all-cause mortality. Now, I wanna point out one thing before we put this topic to bed, which is the Mendelian randomizations typically come up with a slightly different answer than the epidemiology. So the epidemiology usually shows kind of a flat curve for low levels of alcohol, and then a ramp up of mortality as alcohol creeps up. Again, different studies and different cohorts are going to find different places. Um, I generally tell patients that I think conservatively one drink a day is, at least according to the epi, a minimal increase in risk. Um, whereas, you know, that JAMA study found you could get up to two drinks a day, maybe even three, but it was only at three when you started to see the uptick. Um, but the Mendelian randomization, which again is a technique where we look at genes that control a trait, so you might look at genes that control cholesterol or genes that control, in this case, alcohol consumption, because again, um, we know that there are certain genes that make it very difficult for people to drink alcohol. So if you, if you believe that, um, possessing those genes can speak to the phenotype of drinking, and I think this is a decent example of where Mendelian randomizations work. There are some where it doesn't. Um, the MRs show that at any increase in the consumption of alcohol, there is indeed an increase in mortality. So they, um, they show an increasing, increasing level, so we say that that means that the first and second derivative are positive. So any, you know, standard deviation and increase in the consumption of, of alcohol leads to a greater increase in the risk of everything from hypertension to dementia to cardiovascular disease to cancer to all-cause mortality. So how do we reconcile these two things? Well, I mean, I think it's kinda tough, right? Because, um, n-neither technique is perfect. Um, but I think we, we, we sort of have to suggest that the precautionary principle here would be to obviously not consume alcohol at all because it's not an essential nutrient. There's, there's nothing that it's doing that's good for you. Um, and therefore, after that, you just have to be kind of judicious in your use, and you have to ask the question, like, "Is this being maladaptive for my life in any other way? Does it, for example, impair my sleep?" With the, um, ubiquity of sleep trackers out there, I think most people will observe that if you drink a little bit too close to bed, um, your sleep is gonna be disrupted. Does it change the way you eat? For example, if you have a drink or two in you, are you more likely to raid the pantry or the freezer and get ice cream? Um, and then of course, there's the, you know, much more destructive stuff like driving and things of that nature. So, um, I think overall, we can say that alcohol is under no dose helpful, um, under low doses, probably not terribly bad, uh, but under escalating doses, it, it's actually quite negative.

   3. SPSpeaker24:09

      And how would you respond to a patient who says something in the following, which is what you kind of see a lot, which is, "I understand that alcohol may not be good for me, but I do get a lot of enjoyment having a drink with some friends like every other week or once in a while." Do you think that the danger of having a little bit of alcohol outweighs the potential enjoyment of being with friends in that environment?

   4. PAPeter Attia24:38

      No, I think-- Look, I, I, I don't wanna dismiss the importance and the benefit of, of, of social interaction and the, and, and the joy that comes from that. I think it just comes down to the dose, truthfully. So i- if that person says to me, "Look, I just, you know, twice a week or, you know, sorry, twice a month, I like to meet my buddies, and we like to play poker, or we like to watch football, and we have a few drinks," at the surface, there doesn't seem anything wrong with that. But look, if the answer is, "Twice a month, I'm just gonna drink 12 beers," well, I'm gonna say that I, I have a hard time understanding how the pro-social benefit of hanging out with your buddies that day justified having 12 beers. If the answer is, "Yeah, like, you know, I, I, I like to kick back three or four beers, um, a, a couple times a month," then I would say, yeah, it's probably not that bad.

6. 25:26 – 28:53

   Principles of a well-balanced diet: macronutrients, micronutrients, protein, energy balance, and more

   1. SPSpeaker25:26

      Yeah. Moving on to the next set of questions, kind of nutrition related. The first one is: What do you think are the key principles for a, quote-unquote, "well-balanced, healthy diet"?

   2. PAPeter Attia25:40

      [upbeat music] 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 wanna 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 wanna 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. [upbeat music]

Episode duration: 28:54