Peter’s historical changes in body composition & evolving nutrition & training [AMA 44 sneak peek]

1. 0:00 – 0:08

   Intro

   1. PAPeter Attia0:00

      [upbeat music] Hey, everyone. Welcome to the Drive podcast. I'm your host, Peter Attia.

2. 0:08 – 9:49

   DEXA scans and other methods for tracking body composition

   1. SPSpeaker0:09

      Peter, welcome to another AMA. How you doing?

   2. PAPeter Attia0:12

      I'm doing well, but you look awfully cold.

   3. SPSpeaker0:15

      Oh, it's... It is negative degrees right now. It is, uh... It's not good. It's that time of year. I feel like we've got nothing but snow for the past two weeks, so it's just a matter of survival at this point. So, it-- There's nothing you can do. I mean, I know you miss it, and that's kinda why you wanna go back to Canada, is just the weather. So it's, it's fair. But you can always come to Minnesota. You can come live out here.

   4. PAPeter Attia0:41

      I think the whole time I was growing up in Canada, I kept wondering, "Why did people live there prior to the industrial age, like, prior to heat and things like that?" Like, did it not occur to them that, "Hey, I can just walk south for a couple of months, and I'll be in a place where, yeah, it's hotter in the summer, but, like, I don't risk dying in the winter"? Anyway, I don't know.

   5. SPSpeaker1:01

      [chuckles] Well, on that note, we're gonna do a little something different for this AMA. We kinda had a little something else planned. And then recently, in the past week, you've gotten some labs and DEXA results back, and you found them really interesting, and we were talking about them internally. So we kinda decided to pull an audible and instead kinda talk through those, because I think what we've heard from our audience is whenever we can do case studies and see, like, real-world results and then how people tweak it, they've always found that really helpful. And this time, the patient's gonna be you, so hopefully it's even more interesting. And on the cold, which we'll get to in a second, I think the rate you're going, you could survive in the cold a lot longer-

   6. PAPeter Attia1:43

      [chuckles]

   7. SPSpeaker1:44

      ... than you maybe could have 10 years ago.

   8. PAPeter Attia1:45

      Ouch. Ouch. That hurts.

   9. SPSpeaker1:47

      [laughs] Um, so I think, I think what we're gonna do is we're just gonna kinda get into it. It's gonna be a little more old school kinda question and answer and going along the way. But I think what would be helpful is, you know, a few AMAs ago, um, a handful probably at this point, we talked about DEXA, and we went through kind of how you think about that and then also what you do with patients. And so, um, what you have is you have a spreadsheet of DEXAs that you've done over the past 11 years and kind of how your body has changed throughout that time. And I think what we'll do is we'll use that as an anchor to talk about, like, the various things and what you've seen from yours. Because I know in that time you've done a lot of different things, from exercise to nutrition to everything else, and I think it will be a good point to walk through that. So do you wanna just share your screen?

   10. PAPeter Attia2:40

       I mean, I think before I do that, I'll just kinda give a bit of the, the background. So, you know, growing up, um, when my main thing was boxing, obviously weight... That's a very, very weight-driven sport. Um, and especially if you're not a heavyweight, which I was not, I was a middleweight, every ounce of non-essential tissue you carry into the ring is problematic. So, um, we relied on calipers at that time for body composition. And as anybody who's either had a caliper test done or certainly done one or seen it understands, it, it's not the most objective standard, um, and it's highly dependent on the skill of the individual doing the test. Um, that said, a person who really knows what they're doing with calipers is awfully good and, and, and pretty accurate. Uh, fast-forward, um, to, you know, my 30s, the next time I was paying attention to this sort of thing, um, that's when I was doing hydrostatic testing. So you would go to places that weighed you while dry and then weighed you underwater under the conditions of full exhalation. And the ratio of those two weights, your, you know, buoyant weight versus your not, uh, and the use of Archimedes' principle would basically allow them to deduce how much of your weight was fat. That turned out to be a pretty inaccurate way to go about doing things, 'cause again, it, if, if for no other issue, highly dependent on your, um, [lip smacks] w- basically how much air is left in your lungs at the point of exhalation. Uh, so I think it was probably 2011, so almost 12 years ago, I sort of switched over to DEXA scanning. And for all intents and purposes, DEXA is the gold standard. Um, and we've talked about what that is, so I'm not gonna go into it. But basically, it's a type of X-ray that scans your body that effectively divides tissue into the following buckets very accurately: bone, fat, other. So, um, the other is mostly muscle, but of course it's also your organs and things like that. [lip smacks] So, um, w- we look at DEXAs in a number of ways. It's very good at giving total body fat, because it's very accurate at measuring fat. So total body fat divided by total body weight is your body fat percentage. And as we've talked about, that's the thing that most people care about when they get a DEXA scan. When our patients get DEXA scans, and we are really adamant that our patients get DEXA scans at least once a year, I think this is a very important thing to be doing, when I run through the results with them, I always say the same thing. Of the four things we're gonna talk about today, the least interesting of these is your body fat. Um, the three other things that we talk about are your visceral fat, which is one of the compartments of fat that is outside of the subcutaneous stores. That's the areas where we want to store fat. If we're going to put excess energy away, we want it to be in subcutaneous pockets of fat. As our capacity to store fat there gets stretched, we begin to spill over into other places. We talk about this, and I write about this in the book, as the bathtub. So everybody has sort of a different size bathtub. That's their genetic capacity to store fat in the safe subcutaneous space. The water coming in the bathtub is what you're eating. The water leaving the bathtub through the drain is the energy expenditure. You will either be net accumulating or net losing water in that bathtub. But if you get to the point where you exceed your bathtub's capacity to hold water and you start to spill over, really bad things happen. Nobody likes to have even a small amount of water on their floors and God forbid in their drains and heating ducts. And that's what's basically happening when you start to see visceral fat, when you start to see intrahepatic fat. You know, NAFLD is the earliest stage of that. When you start to see peripancreatic fat, perinephric fat, pericardial fat. All of these things are really problematic, highly inflammatory, and, um, y- you know, effectively what I would call the fourth pillar of disease. So for example, if you're talking about ASCVD, we talk a lot about ApoB, blood pressure, smoking. We don't want to forget the inflammatory effect of those fat sources. So, so that becomes the second thing we care a lot about. Third thing we care a lot about is bone mineral density. So we care about a person's Z-scores and T-scores. Recall from the podcast we did on that, the Z-score is your age, sex matched, um, uh, BMD for your lumbar spine and your hips. The T-score is comparing you to a 30-year-old. We use the T-score to make the diagnosis of osteopenia if that's one standard deviation below the mean or osteoporosis if you're, I believe, two and a half standard deviations below the mean. The fourth thing we look at are the metrics, the two metrics of muscle mass, which are ALMI and FFMI, appendicular lean mass index and fat-free mass index. These are two different methods to triangulate on the same sort of thing, which is basically how much muscle mass do you have for your, uh, height. So the ALMI is calculated by looking at the lean mass in your arms and legs in kilograms, dividing that by your height in meters squared. The FFMI takes the total fat-free mass in your body and divides that by your height in meters squared. Obviously, FFMI is a much bigger number than ALMI. The absolute numbers aren't what matters. What matters is where do you show up on the nomogram for your age and your sex, and we want our patients to be north of the 75th percentile for ALMI and FFMI based on the data we've shared previously. Um, okay. So with all that said, I have kept a spreadsheet for, you know, better part of 12 years where I log my DEXA data and, um, I think, you know, it'll be interesting to go through some of that now. So again, let me just set the context because I think what we'll do when we go through this, so people that are just listening to this, I think I'll, I'll do my best and Nick, you'll do your best. We'll, we'll try to talk about the numbers, but the reality of it is this is one of those things where it's probably helpful to be watching a screen when we talk about this stuff. Um, we're gonna kinda talk about what we're, what was happening in my life at each of these time points. How did things change? 'Cause really there's a bunch of variables. There's, you know, the passage of time, more than a decade. There's many changes in nutrition from very strict types of diets to fasting to completely unrestricted eating. Uh, and then obviously there's dramatic changes in the type of exercise that's been going on there. Those are really the fundamental, uh, three changes. Um,

3. 9:49 – 11:19

   Importance of tracking data over time to see trends

   1. PAPeter Attia9:49

      anything else before we jump into this?

   2. SPSpeaker9:52

      One thing I was gonna say is I think anyone listening won't be surprised that you keep a spreadsheet of data of like across different health metrics, and it's something that you do beyond just DEXA. But I've heard you talk a lot about it, and I know with patients, like internally you create kind of a trend sheet, which is let's, uh, like let's do a lot of work to upfront get all their historical labs so then we can see how does this number compare historically as opposed to looking at this number isolating. And so as much of a pain as it is for people, whether it's DEXA or even labs, you put a high value in being able to look at something like this where you can say, "Let's look at historically, let's monitor changes," as opposed to like, "Oh, I got a DEXA, I'm just gonna look at it this time. I got my blood run. Let me look at what it is now and then not focus on everything else." Correct?

   3. PAPeter Attia10:46

      Yeah. And, and there are companies that do this kind of stuff. I mean, we, we, we kind of build our templates in-house. Um, I'm not, uh, I'll, I guess later I'll show kind of our in-house template for how we present the data and then of- obviously you just have kind of like a, a table that records the historical data. So you kind of present the exi- the current data in sort of graphical form and then include that along with all the historical data in tabular form so you can see the trends. Um, but yes, I mean, I think, you know, trends matter. Um, you're treating what you see, but you're, you're, you're mindful of the trends.

4. 11:19 – 18:06

   DEXA scans in 2011: swimming, lifting, and a carb-restricted diet

   1. PAPeter Attia11:20

      Um, okay. So let me do a little screen share here and pull up the, uh, DEXA data. Uh, okay. So what you're looking at here is a relatively straightforward, uh, spreadsheet that simply, uh, records the data as they've, uh, been laid out going back to, uh, May of 2011. What's interesting is that was the first DEXA scan I ever had, and I did it the same day that I had a, um, hydrostatic dunk test. So I had been, you know, every couple, e- every, maybe every year doing a hydrostatic dunk test and on that particular day, uh, and maybe it was the day before, but it was pretty... I think it was the same day. Um, I had a hydrostatic dunk test and it said something like 16% body fat, and I was like, [lip smacks] "Boy, I sure don't look like I'm 16% body fat." Um- And then I decided to go and splurge for the DEXA 'cause at the time, you know, there's... And there probably is still con- a significant difference in price. So I went and had the DEXA scan, and it was like, "No, you're actually 9.3%," which was kinda more in line with what I felt like I was, and that was basically the last time I ever did a hydrostatic test. Now, why again was there such a discordance between them? I don't know. Maybe I'm someone who can't get a lot of air out of his lungs and, um, and therefore wasn't, you know, giving a good enough underwater weight relative to above water weight. But regardless, uh, you know, that, that's where I was, call it, uh, 12 years ago. So as you can see, um, just to orient you to the columns, body weight at the time, uh, was just under 180 pounds. And then what's being spit out is what the DEXA scan is really good at telling you. It's able to tell you how much lean mass you have, so that's basically muscle and organs, call it 156 pounds. How much fat mass? 16.8 pounds. The mass of bone mineral content, seven pounds. And then fat-free mass, which as you can see, is just the sum of lean mass and bone mineral content, 163 pounds. So body fat is calculated at 9.3%. Now, unfortunately, this was back when I lived in San Diego, and I was doing these at San Diego State University or something, and they just didn't have the software at the time. They weren't spitting out VAT. So I don't have VAT recordings. Um, [lips smack] furthermore, they probably gave segmental information on their reports, but I wasn't paying attention to it. So I-- when I, you know, a couple years ago, started paying attention to ALMI and FFMI, didn't have the data. I even called them up, and they didn't have the reports. So back then, all I could tell you was what my fat mass index was, and again, I don't really pay that much attention to that metric, but I do record it, uh, and what my fat-free mass index was, and we'll talk about that. But I don't have ALMI until 2014. [lips smack] Okay. So what can I say looking at those numbers? So a body fat of 9%, and I would've been 38 years old. Um, so I'm gonna pull up my table of, um, [lips smack] what that is. So, you know, that's, that's low, right? That's sort of below the third percentile, so that's, that's, that's really lean. And for an FFMI of 23.4 at that age, 23.4, um, it's above the 97th percentile. That's the highest line on the nomogram. Okay. So that was... So what was I doing at the time? I guess that's the more important question. So that's back in an era where I was swimming a lot, and that was kinda my main thing, like pool swimming. I was kinda done with open water marathon swimming. I was lifting weights like crazy and doing a little bit of cycling as, um, [lips smack] kind of cross-training. And I was on a carb-restricted diet, but not a ketogenic diet. So this was right before I started a ketogenic diet. In fact, this is the month I went on a ketogenic diet, was, uh, May of 2011. So I was pretty carb restricted for a year before that. Okay. So fast-forward to the end of that summer. I'm now, I don't know, whatever, t- two, three months into a ketogenic diet. I go and repeat the test. I've lost weight. So I've gone from, you know, 180 pounds down to, call it, 172 and a half pounds. Lost about seven pounds. Uh, some of that is lean. So let's say I went from 156 down to 152 and a half, so lost about three and a half pounds of muscle, uh, but lost about four pounds of fat. [lips smack] Uh, BMC doesn't change. And so body fat's actually gone down a little bit to 7.5%. And, um, but also my fat-free mass index has gone down a little bit to 23%. Obviously still, uh, you know, plenty high. Just for reference, at that age, my goal would be to make sure that my fat-free mass index is above about, mm, 19. That would be kind of the 75th percentile.

   2. SPSpeaker16:51

      And real quick, that's the 75th percentile for FFMI is what you want your patients at, above, 75% or above?

   3. PAPeter Attia16:59

      Yeah. And, and, and if, if I'm g- uh, when there's discordance between the ALMI and the FFMI, we tend to prefer the ALMI 'cause it's... We actually have more data for ALMI. It's also a slightly more pure measurement. Why? Because in your limbs, you really only have muscle, fat, and bone. So the ALMI truly tells you about what its name suggests, the appendicular lean mass index. It is the index of muscle mass in arms and legs. The fat-free mass index, I guess I need to be, you know, a little more clear, is also true to its name, but the reality of it is it is somewhat confounded by the organs. And, um, [lips smack] so, so while we do that, because it includes the musculature of the torso and things like that, um, you'll, you'll sometimes see percentile discordance. And in fact, you see that in me, so we'll, we'll see that when we get to more recent data, [lips smack] that I'm slightly discordant between those two. My FFMI tends to represent me at a higher percentile than my ALMI, probably 'cause I just have, you know, scrawny little arms. Um,

5. 18:06 – 24:03

   DEXA scans 2012-2014 during Peter’s time on a strict ketogenic diet

   1. PAPeter Attia18:06

      [lips smack] okay. So as we march through 2011, 2012, you know, and 2014, tho- so you can see all of those, uh, tests, those are all my keto days. So what am I doing during this period of time? Well, from 2011 to 2012, I now transition into cycling So you see this change in my exercise where I am now spending just as much time exercising, but now it's on a bike, maybe even slightly more time. So I'm still, you know, lifting weights, but not quite as much. Uh, but I'm on a bike five days a week. Two of those days are really, really long days, uh, Saturday, Sunday. And, um, and then there's three weekdays where they're, you know, probably still ninety minutes to two hours. I'm still on a ketogenic diet. Um, and again, I've talked in, about that a lot, probably documented that. I'm sure I've written about it someplace. Um, not really experiencing any downside of a ketogenic diet other than the, you know, the restriction that obviously comes from it. Um, and, uh, you can see at one point at... This isn't my lowest weight. My lowest weight was about 164 pounds, but my lowest weight captured on a DEXA was on, um, was in October of 2012, and that was 167.5 pounds. Now, by that point, my lean mass was down to, uh, about 145 pounds. So that's, um, you know, like 11 pounds less than, uh, the initial test in April, uh, pardon me, in May of 2011. Um, my body fat percent was like, what, nine and a half percent. And my ALMI... Uh, sorry, we're still not calculating that, but my FFMI is still about 22. So y- as I, again, as I talked about, I sort of decided at the end of, or the middle of 2014, that summer, that I was just kind of done with a ketogenic diet. Um, again, I had, you know, I, I think all my metrics of health were really good. Uh, my blood markers were great. My performance was great. It takes a while to adapt. I want to be really clear. It took, it took three months to just even get over the, the, the cliff of, uh, maybe get over the hump, I should say, of feeling kind of miserable when I exercised, and I would say it took me 18 months to get to the point where I couldn't distinguish between being on and off carbohydrates. But there's no question that it's just a very restrictive way to eat. And so in the middle of 2014 is when I started to experiment with fasting. So, um-

   2. SPSpeaker20:53

      And r-

   3. PAPeter Attia20:54

      Yeah

   4. SPSpeaker20:54

      ... real quick on the... When you were on the ketogenic diet, do you have an idea of how much protein you were having during that time compared to now? Because I know you talk so much about protein being so important and seeing your lean mass drop, like, 11 pounds from May of 2011 to February of, or to, oh, February of 2014, it actually dropped six pounds. Um, were you getting as much protein as you are now, you think?

   5. PAPeter Attia21:25

      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 member. We created the membership program to bring you more in-depth exclusive content without relying on paid ads. Membership benefits are many, and beyond the complete episodes of the AMA each month, they include the following: ridiculously comprehensive podcast show notes that detail every topic, paper, person, and thing we discuss on each episode of The Drive; access to our private podcast feed; the Qualies, which are a super short podcast, typically less than five minutes, released every Tuesday through Friday, which highlight the best questions, topics, and tactics discussed on previous episodes of The Drive. This is particularly important for those of you who haven't heard all of the back episodes. It becomes a great way to go back and filter and decide which ones you want to listen to in detail. Really steep discount codes for products I use and believe in, but for which I don't get paid to endorse, and benefits that we continue to add over time. If you want to learn more and access these member-only benefits, head over to peterattiamd.com/subscribe. Lastly, if you're already a member, but you're hearing this, it means you haven't downloaded our member-only podcast feed where you can get the full access to the AMA, and you don't have to listen to this. You can download that at peterattiamd.com/members. You can find me on Twitter, Instagram, and Facebook, all with the ID peterattiamd. You can also leave us a review on Apple Podcast or whatever podcast player you listen on. 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 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 such companies. [outro music]

Episode duration: 24:03