Outlive: The Science and Art of Longevity — Dr. Peter Attia

1. 0:00 – 0:19

   Start

   1. TFTim Ferriss0:00

      [upbeat music] Dr. Attia. Peter, nice to see you.

   2. PADr. Peter Attia0:18

      Good to see you, man.

   3. TFTim Ferriss0:18

      [chuckles]

2. 0:19 – 12:50

   How and why Peter’s muscle mass has increased significantly.

   1. TFTim Ferriss0:20

      I wanted to start with the personal. We're gonna get into all sorts of topics, many different aspects of your practice, lessons learned, et cetera. But I went to your house recently. We had some Topo Chico and a bite to eat and a few other things, and I commented on how much larger you were, and not larger as in obese, but muscularly larger. So I thought we would begin with the question of how and why, not necessarily in that order, you added so much muscle mass.

   2. PADr. Peter Attia0:52

      Well, in the, the fall of 2021, I had sort of hit a relative low in weight that wasn't quite as low as where I was as a cyclist, which was probably about 165 pounds, but was still pretty low for me, kind of in the low to mid-170s. And I did a DEXA scan, which I do periodically, probably a couple times a year, but I hadn't done one in a few years. And when I get my DEXA scans, you know, I always plot the data, right? So I'm not just interested in body fat, but also, you know, bone mineral content and many other metrics. But one of them that's really important is something called appendicular lean mass index, or ALMI. Another one is called FFMI, fat-free mass index. And it's probably worth explaining a little bit about what these are, but the ALMI takes what the DEXA scan imputes as the lean tissue in your arms and legs in kilograms, divides that by your height in meters squared, so it spits out a number like eight kilograms per meter squared. This is a pretty accurate representation of how much muscle you have in your arms and legs because the DEXA scan can really only identify three things: bone, fat, and other. And since things in your arms that are not bone and fat tend to be muscle, it's pretty good at identifying muscle. Whereas the fat-free mass index looks at the entire body and just subtracts out fat. That's also a good proxy for lean mass, but there are many other things, like organs, that are taking up some residence there. Anyway, when I looked at these metrics, I was shocked. I was shocked at how much less muscle I had than 10 years earlier, almost exactly 10 years sooner. And, you know, I attribute it to several things, but I really thought that chief among them was just how much fasting I had been doing over the previous-

   3. TFTim Ferriss2:43

      Mm-hmm

   4. PADr. Peter Attia2:43

      ... three years. You know, I had really kind of taken fasting to a pretty extreme place, you know, doing up to 10 days of water only and routinely just busting out seven-day water-only fasts. Certainly doing three days every month would be, you know, something I would do without hesitation.

   5. TFTim Ferriss3:02

      When you say 10 days of water only, over what period of time is that?

   6. PADr. Peter Attia3:06

      Meaning, like, how frequently would I do that?

   7. TFTim Ferriss3:08

      Yeah, I'm just wondering what the cadence was, if we take it as a minimum to be-

   8. PADr. Peter Attia3:12

      Probably quarterly.

   9. TFTim Ferriss3:13

      Got it.

   10. PADr. Peter Attia3:14

       Yeah, probably every quarter. And while I certainly think there are some benefits from doing that, I think what I was sort of confronting was, wow, there's actually a pretty big cost as well.

   11. TFTim Ferriss3:25

       Mm-hmm.

   12. PADr. Peter Attia3:26

       And I would go out of my way while fasting to still exercise. I was lifting weights every single day, which was difficult sometimes, but doing everything I could to sort of try to stimulate muscle protein synthesis. But at the end of the day, if you're not providing any nutrients- [chuckles]

   13. TFTim Ferriss3:41

       [chuckles]

   14. PADr. Peter Attia3:41

       ... including amino acids, you're basically just tearing down muscle to try to rebuild with that muscle, but your, your net effect is, is a loss. So I, I kind of just said, like, "I gotta, I gotta fix this," like, "I gotta do something about this," and I don't... You know, I wanna have my ALMI be in the at least the 90th percentile, if not above the 97th percentile as I age. The data are pretty unambiguous that people live longer, better lives with an ALMI north of the 75th percentile, so, you know, not one to just clear the bar. I wanna be considerably above the bar. So basically, I just changed things around and said, you know, nutrition and exercise are gonna change a little bit. So, you know, we can talk about those changes, but basically, I made big changes with, with exercise and nutrition.

   15. TFTim Ferriss4:28

       How much lean mass did you gain over what period of time, would you say, once making these changes?

   16. PADr. Peter Attia4:36

       So in a span of... Oh, God, I'd have to go back and look at the exact data. I believe it was 13 or 14 pounds of lean mass in about 12 months.

   17. TFTim Ferriss4:46

       Mm-hmm.

   18. PADr. Peter Attia4:48

       Which is, again, that's not Herculean, right? Like, these are not-

   19. TFTim Ferriss4:50

       Yeah

   20. PADr. Peter Attia4:50

       ... insane numbers. Not taking anabolic steroids, this is, you know, relatively doable for someone who is making it a high priority to eat the right amount of protein, the right-

   21. TFTim Ferriss5:04

       Mm-hmm

   22. PADr. Peter Attia5:04

       ... kind of protein, and spacing it and consuming it at the right times, and then also focusing training on a little more hypertrophy.

   23. TFTim Ferriss5:13

       So for people listening, I'm asking these questions not simply because I'm interested in lean muscle mass, but also the implications for longevity. So I'm guessing you did not put all of that lean muscle on your biceps- [chuckles]

   24. PADr. Peter Attia5:25

       [chuckles]

   25. TFTim Ferriss5:26

       ... and that there were other movements that were incorporated for very particular reasons, if I, if I'm getting my read on Dr. Peter Attia right, as I think I am. So perhaps you could just describe some of those changes. And also protein and how you suggest people think about protein and how you began thinking about protein.

   26. PADr. Peter Attia5:50

       Yeah, I'll start with that, and then we can talk about the training. So the, the, the protein basically went to a very conscious and concerted effort to increase protein to one gram per pound of body weight.

   27. TFTim Ferriss6:01

       Mm-hmm.

   28. PADr. Peter Attia6:02

       People are gonna ask, is that one pound of actual body weight? Is that one pound of lean body weight? Is that one pound of target body weight? The answer is for someone my size and weight and my body fat percentage, I think at the time I was about 15% body fat, it really doesn't matter. It could be basically call it one pound of current body weight. One gram per pound of current body weight is sufficient. So that's what I did. The next question, though, becomes timing, and this is something that-

   29. TFTim Ferriss6:28

       Right

   30. PADr. Peter Attia6:29

       ... until a couple years ago, I wasn't really paying enough attention to. So it, it wasn't enough to just say, "Well, Peter, you gotta have 180 grams of protein in a day," because, for example, two 90 gram boluses of protein doesn't accomplish nearly the same thing as four 45 gram servings spread out over the course of a day. So there is kind of a sweet spot with protein where you really need to be north of about 20 to 25 grams to ensure that those amino acids aren't just going into what's called the gluconeogenic pathways. We can turn protein into glucose, but we don't really want to.
3. 12:50 – 17:42

   Why the long wait for Outlive: The Science and Art of Longevity?

   1. TFTim Ferriss12:50

      be aiming for. So let's come to the book. So you and I have had many offline conversations about the book.

   2. PADr. Peter Attia12:57

      [laughs]

   3. TFTim Ferriss12:57

      We'll probably not repeat some of them. Why did it take so long? And I believe there were three iterations over six years, and the first iteration had a zero translation into the final version, something along those lines.

   4. PADr. Peter Attia13:12

      Yeah.

   5. TFTim Ferriss13:13

      Maybe you could correct me if I'm getting that wrong. But-

   6. PADr. Peter Attia13:15

      [laughs] No, that's correct

   7. TFTim Ferriss13:16

      ... why have you taken so much time to work on this book?

   8. PADr. Peter Attia13:21

      Yeah, it's a really good question, Tim. I think there are probably several factors, some of which are related, some of which are not. I think on one level, my appetite for how good, quote-unquote, I needed this book to be was very high.

   9. TFTim Ferriss13:37

      [laughs] That's so unlike you, Peter. [laughs]

   10. PADr. Peter Attia13:39

       Yeah, yeah, yeah. Look, I think there are some people out there who can churn out a book a year, and more power to them, but, you know, the way I viewed this book was that this is sort of the one and only book I ever wanna write. Will I ever write another book? It's, it's hard for me to ever imagine the answer to that question is yes, but again-

   11. TFTim Ferriss13:57

       [laughs]

   12. PADr. Peter Attia13:57

       ... maybe, maybe at the end of my life I'll have something else to say. But as, as, as I'm 50 years old now and I'm at the midpoint of, of my life, or slightly past the midpoint of my life, I feel like everything I ever wanna say on this particular topic is in this book, and therefore, you know, it was just a very long book, right? I mean, it took-

   13. TFTim Ferriss14:15

       Mm-hmm

   14. PADr. Peter Attia14:15

       ... like the final version is probably 140,000 words. The version I ultimately submitted was 200,000 words. Like this-

   15. TFTim Ferriss14:23

       Mm-hmm

   16. PADr. Peter Attia14:23

       ... has been chopped way down by 30% into what is still, you know, obviously a, a, a book that is, is, is, is quite long. So that's part of it. I also think part of it is, and maybe you can relate to this, Tim, I don't know, we've never actually talked about this, but I think there's just a vulnerability that comes with writing in this manner that is unlike all the writing I've done in the past. So I've been blogging insanely for 12 years. That's different, right? You're not really putting yourself out there when you write a blog post.

   17. TFTim Ferriss14:59

       Mm-hmm.

   18. PADr. Peter Attia14:59

       You don't have to read the comments that people write. You don't have to pay attention to any of that stuff. I think when you write a book, you are really saying to people like, "Here I am. Tear me down," you know? [laughs] And I just think there's, on some level, and maybe it's embarrassing to say this, there's just been a little bit of a reluctance to, to kind of be that, yeah, again, for lack of a better word, vulnerable.

   19. TFTim Ferriss15:23

       Mm-hmm.

   20. PADr. Peter Attia15:24

       Just to sort of say, "Okay, you know, I'm willing to say everything I have to say on a subject matter, and now let the arrows come flying." And, and that's, again, I, I don't know that that makes sense, but I'm sure that anyone who does something very public feels that way, but it's different with podcasting, which I don't have a problem doing, and it's different with blogging and, which I don't have a problem doing, but this strikes me as maybe what an actor feels like when they make a big film, or a director, or again, like, like an author like you. So I think there was a little bit of subconscious dragging my feet and, hey, maybe I can just keep working on this book forever, but it'll never actually come out.

   21. TFTim Ferriss15:59

       [laughs] So I do identify, and I would say for me at least, part of that is when you put out a book, it might be one of the 20 books the publisher is working on that season, but especially if it's a book of this depth. And also, I will second vulnerability, not just on the personal side when discussing physical health, but also in the chapter, or I should say section really, on mental health, psycho-emotional health, and so on. I mean, you really show sides of yourself that are uncommonly shown, I think, in some of your other formats. And unlike a blog post, it's very hard to just delete a book from [laughs] the world once it is published. So I, number one, think it was right to take it seriously, and however long it takes to do a book of this quality is the time that it takes, and I think that's the way it should be. And I will say, just as a side note, I mentioned this to you, and you know this, that my dad, who has struggled in various ways with health for decades now, picked up your book, which I had at home when he was visiting me in Austin, and could not put it down. And that is, I have to... I won't get into all the details of why this is the case, but, like [laughs] if that isn't a testimonial, I cannot imagine what is. To the extent that I ended up giving him my copy so that he could take it home. So that should tell everybody something.

   22. PADr. Peter Attia17:32

       I didn't know that, Tim. Thank you. 'Cause, uh, when you guys came over-

   23. TFTim Ferriss17:35

       Yeah

   24. PADr. Peter Attia17:35

       ... he mentioned how much he was liking it. He had just picked it up, but I didn't realize he'd finished it and he enjoyed it, so thank you. That, that means a lot.

4. 17:42 – 22:58

   Objective, strategy, and tactics.

   1. TFTim Ferriss17:42

      Yeah, definitely. And with that, let's talk about, perhaps this is a good place to start, objective strategy tactics. Why are these three pillars important and why all three?

   2. PADr. Peter Attia17:57

      You know, I learned about this stuff about a decade ago when I was working on a problem that, you know, is irrelevant now, but I think the, the message was important, right? Which was, I think I had a vague sense of what the objective was, and my immediate tendency, which I think is normal, and I think we all do, 'cause I don't think anyone's hardwired to go through the middle step- was to go from objective to tactics. In fact, I think most people just kind of go to tactics without even thinking about objective. And certainly not having that strategy piece in the middle makes life really complicated. So the first thing, I think, is to understand what's the difference. So objective is pretty straightforward. It needs to be stated. It should be very clear, though. So for example, my objective might be to live longer.

   3. TFTim Ferriss18:49

      Mm-hmm.

   4. PADr. Peter Attia18:49

      Okay? If you said, "Well, what are the tactics now? What should I eat? How should I exercise? You know, do I need to take this supplement or that supplement?" The probability that you are going to come up with the right set of instructions is vanishingly small, right? It's somewhere between zero and epsilon small.

   5. TFTim Ferriss19:07

      Even if provided this list, this laundry list of tactics?

   6. PADr. Peter Attia19:12

      Well, I guess the question is how do you come up with the list, right? Like how are you-

   7. TFTim Ferriss19:15

      I see what you're saying

   8. PADr. Peter Attia19:15

      ... filtering on that list, right? So-

   9. TFTim Ferriss19:17

      Mm-hmm

   10. PADr. Peter Attia19:17

       ... so there's no shortage of tactics that one could think about because the world is rife with everybody offering their tactics.

   11. TFTim Ferriss19:23

       [laughs]

   12. PADr. Peter Attia19:24

       It's not like I'm not suggesting tactics, but what I really want people to do is say, "Look, let's anchor to a strategy." So for example, if one of your objectives is, "Okay, I'm gonna live longer," it's like, no, no, let's deconstruct that. What does living longer mean? Well-

   13. TFTim Ferriss19:37

       Mm-hmm

   14. PADr. Peter Attia19:37

       ... to understand what it means to live longer, you have to understand what ends life.

   15. TFTim Ferriss19:41

       Mm-hmm.

   16. PADr. Peter Attia19:41

       Well, what ends life is a very clear and easy-to-understand data set, so let's look at it. And let's look at it in great detail. We call this the death bars analysis. So what are the death bars? Well, it turns out if you're over 40, you don't smoke, we can really clearly tell you that there's about an 80% chance you're gonna die from atherosclerotic cardiovascular disease, cancer, neurodegenerative disease, or metabolic diseases, you know, such as Type 2 diabetes and things like that. And probably I would include accidental death in there, so falling-

   17. TFTim Ferriss20:16

       Mm-hmm

   18. PADr. Peter Attia20:16

       ... or automotive accidents. Okay, so that's, that's an important insight because now you start to work backwards from there. So if you ... So wait a minute, you're thinking, "Oh, if I wanna live longer, I have to avoid those things. Ah. Okay, how do I avoid those things?" Well, let's start with the chronic disease bucket. There's two ways to think about that, right? This is... I love when things turn into somewhat binary decisions. Is one way to live longer to live longer with a chronic disease or live longer without a chronic disease? So might not be entirely obvious which of those is true, but if we look at the data, it's pretty clear. The data unambiguously make it clear that you will live longer if you can extend the period of time that you live without a chronic disease rather than extend the period of time you have the chronic disease. So in other words, it's better to get cancer later in life than to live longer with cancer, as one example. It's better to have your first heart attack very late in life than have it early in life and then be right on the verge of having another one as time goes on. Well, just by going through those very simple questions, all of a sudden you start to formulate a much clearer strategy for living longer that points you much more clearly towards this idea that I talk about in the book called Medicine 3.0 rather than Medicine 2.0. And once you iron all that out, then you start to get into the tactics. Oh, all right, okay, so how does nutrition layer onto this? How does pharmacology layer onto this? How does exercise layer onto this? Et cetera.

   19. TFTim Ferriss21:45

       So I wanna just share an anecdote which will not surprise you, but when I published The 4-Hour Body, and no doubt you're gonna get a lot of these types of requests if you haven't already, I had a number of not morbidly obese, but out of shape CEO friends say, "Look, I just want the index card. Just give me the index card with the seven things I should do-

   20. PADr. Peter Attia22:08

       [laughs]

   21. TFTim Ferriss22:08

       ... and I'll do those seven things." Can you guess what the compliance rate was with that, Peter? What's your, what's your guess? [laughs]

   22. PADr. Peter Attia22:15

       Very close to the success rate of skipping the strategy step.

   23. TFTim Ferriss22:19

       [laughs] 0%.

   24. PADr. Peter Attia22:21

       Yeah.

   25. TFTim Ferriss22:21

       Not a single one of them actually implemented any of it. [laughs] And just as a, a quick side note which you might find entertaining, I had an amazing mega-successful investor named Ed Thorp on the podcast who's, uh, if not, if not over 90, 90 right now. He's in excellent shape, and he plans his travel around minimizing time in automobiles.

   26. PADr. Peter Attia22:47

       Mm-hmm.

   27. TFTim Ferriss22:47

       And he's sort of run through the numbers just as a, as an anecdote.

   28. PADr. Peter Attia22:51

       Very underappreciated cause of, of morbidity and mortality.

   29. TFTim Ferriss22:55

       Yeah.

   30. PADr. Peter Attia22:56

       I think about it a lot.

5. 22:58 – 34:20

   From Medicine 1.0 to Medicine 3.0.

   1. TFTim Ferriss22:58

      Yeah, we might come back to, as I think about it, different seat belts that you can use in life, which initially, I don't wanna turn this into a Tim Ferriss TED Talk, but initially thought about-

   2. PADr. Peter Attia23:09

      [laughs]

   3. TFTim Ferriss23:09

      ... with respect to COVID early [laughs] which was, like, what minimally inconvenient, easy-to-do things can you do to dramatically mitigate risk, right? Like, so e- even though you've never had a head-on collision, the downside of having a head-on collision is so high that most of us will wear a seatbelt when driving on the highway. Most of us will have a fire extinguisher in the kitchen even though there's never been a fire in your kitchen, et cetera. So where else can we take very small steps that are easy, low cost, that prevent dramatic downside risk? So we may come back to that, but I want to bring up a graph that you have in your book, page 28 for those who wanna find it, [laughs] where if you remove the top eight contagious/infectious diseases, it appears that we, meaning we're, we're accounting for the advent of antibiotics, at least as I understand it. We haven't really seen a material or at least large change in mortality rates since what, 1900, if you sort of account for some of these variables. Why do you think that is? 'Cause certainly most people don't wanna die.

   4. PADr. Peter Attia24:20

      [laughs] Yeah. So, so you're absolutely right. So life expectancy since 1900 to today has increased by twofold. It's remarkable. It's gone from about 40 to about 80, right? You know, plus or minus. But that's directionally the change we've seen in, call it, 120 years. And I do think that understandably, it's tempting to tout that as the marvels of modern medicine. And you're thinking, "Well, oh my God, we went from 40 to 80 in 120 years. The next 40, just based on Moore's law, that's gotta get us to, like, 160, right?"

   5. TFTim Ferriss24:56

      [laughs]

   6. PADr. Peter Attia24:57

      Okay, maybe, but let's take a closer look at the data. So you do this very simple analysis, which is, okay, let's go back to 1900 and march forward, but when we go through the mortality tables, just strip out the top eight leading infectious disease causes of death. And what you see is exactly what you describe. There is now no change in mortality from then until now, effectively. There's a little bit. It's been a little bit better. And I think what it speaks to is two things. One is the remarkable success of Medicine 2.0 in solving acute care and infectious diseases, and the remarkable failure of Medicine 2.0 in addressing the chronic diseases that sat under the surface of the water waiting for the tide to go down.

   7. TFTim Ferriss25:53

      Mm-hmm. And those would be presumably the four or five likely causes that you mentioned earlier. Perhaps this is a good place for you just to define or describe briefly Medicine 2.0 and Medicine 3.0.

   8. PADr. Peter Attia26:11

      So it's probably easiest to just for the sake of completeness start with Medicine 1.0. Medicine 1.0 was basically everything that occurred prior to the transition period of the late 17th century into the late 19th century. So that 200-year period marks a transition from when medicine had absolutely no basis of science whatsoever. So, I mean, we can mock it now, but truthfully, they didn't have a scientific method or a scientific tool, so they, all they could do was sort of think about the gods, think about bad humors, you know, come up with the best rationalization they had for what was going on. In fact, arguably the most insightful thought that occurred in Medicine 1.0 was thousands of years ago on the part of Hippocrates, who was the first to believe that diseases were somehow caused by nature and not the gods. That, that was truly a remarkable insight. Now, beyond that, he had no clue what was going on, but that was a remarkable insight, and that was probably the apex of Medicine 1.0. With Francis Bacon in the 17th century, we had basically the first push towards the scientific method. This, this became really important, and no one has done a better job explaining this than our mutual hero, Richard Feynman. There's a great video, which I'm sure you guys can find for the show notes, where it's an old grainy black and white where Feynman is talking about the scientific method, and he's saying, "Look, you, you make a guess," right? "You design an experiment." It's-- the guess is called a hypothesis, by the way. It's just a fancy word for a guess.

   9. TFTim Ferriss27:51

      [laughs]

   10. PADr. Peter Attia27:51

       You design an experiment to test that hypothesis. You do the experiment, you compare the results of the experiment to your guess, and then you decide to either discard or update your hypothesis. This was such a profound concept that it basically propelled us into Medicine 2.0, and the place where that shone greatest was unquestionably in the world of microbacteria, right? Of microscopic organisms, so viruses and bacteria. And so, you know, again, that's a bl- it's a brutal, bloody slog to go from, you know, Semmelweis to Koch to Lister, but that transition effectively brought us into the modern era where, hey, all of a sudden, doctors were washing their hands and not operating on people with dirty hands. And, you know, and of course, eventually we had antibiotics, and eventually we had vaccines. And, you know, taking smallpox and polio off the table and reducing the mortality of influenza and having antibiotics, all of that stuff had such a profound impact on human health that it cut mortality rate down by half and doubled our life expectancy. So now we're into the maturation of Medicine 2.0. We saw these other amazing success stories. I think the two most notable by far would be hepatitis C and HIV. I mean, to think that we're at a point now where a virus that is as tricky as HIV can basically be rendered a chronic disease on the back of highly active antiretroviral therapy is nothing short of amazing. When I was in medical school, Tim, we're not talking, like, a long time ago. This was 25 years ago. We were told hep C will never be cured, and it will break the back of the US and global transplant infrastructure, meaning we're gonna need so many livers to put into all these people with hep C-

   11. TFTim Ferriss29:48

       Mm-hmm

   12. PADr. Peter Attia29:48

       ... that by 2030 the system will break. And lo and behold, we have a drug that within a manner of weeks will eradicate this thing. So-

   13. TFTim Ferriss29:57

       Hmm

   14. PADr. Peter Attia29:57

       ... again, huge successes. Now counter that with what we've done against cancer.

   15. TFTim Ferriss30:04

       Mm-hmm.

   16. PADr. Peter Attia30:05

       When Richard Nixon declared the war on cancer before you and I were born, it was more than 50 years ago, the goal was to eradicate this disease by the bicentennial in 1976. Well, not only did that not happen, but here we are more than 50 years later, and survival for cancer is barely 5% greater than it was in 1970. Hmm. I could go on and on, but let's just look at neurodegenerative disease. So you were talking about six million people with Alzheimer's disease in this country. If you add up those with Lewy body dementia and Parkinson's disease, we're talking about, gosh, another four and a half million. So we're looking at more than 10 million people in this country with very, very significant neurodegenerative diseases, and that says nothing about, you know, ALS and Huntingtons and things like that. We don't have a single thing, like a, a single thing that we can do to, to cure these people, right? We, we have barely a few things that can slow the progression of their diseases. But we've made, you know, paltry steps against chronic diseases. When you and I were born, the prevalence of type 2 diabetes was less than 1%. Today, it's 10%, effectively, right? So we've seen a log fold increase in type 2 diabetes. 100 to 120 million people in the United States are metabolically sick, meaning have metabolic syndrome or pre-diabetes or type 2 diabetes outright. So something's not working, right? And the current system of Medicine 2.0 doesn't really seem equipped to address it. It intervenes late, and by the time it's intervening, it's not really fixing. So this thing I'm proposing, this idea that of course I'm not the first person to suggest, maybe I'm the first person to talk about it this way, is we wanna kind of pivot to this newer way of thinking about things, which deviates from Medicine 2.0 in a couple of really important areas. The first is in its timeline. So Medicine 2.0 is largely focused on treating disease, and it's really interesting when I think about it 'cause it's so obvious that I can't believe I didn't notice it earlier. But when you're in medicine, when you're in medical school, when you're in residency, when you're in practice, you sort of need a code for a disease. You need a code for a disease that you bill for and you treat. And prevention doesn't really fit into that. So, you know, when I went to medical school, I didn't learn a single thing about nutrition or exercise or sleep or stress management or emotional health. I learned a lot about pharmacology. And it's tempting at this point to say, "Well, pharmacology is either good or bad." No, it's, it's both, right? Like, pharmacology is good and it's really valuable, but over-indexing it is bad.

   17. TFTim Ferriss33:01

       Right.

   18. PADr. Peter Attia33:01

       And ignoring all those other things is problematic. Those other things turn out to be far more efficient tools of prevention. But if, if no doctor learned about them, then why are we surprised that Medicine 2.0 is unable to cope with that? So, so one, we have to understand prevention, and we have to understand the timeline for prevention must start much sooner. You have to start doing these things long before diseases are kinda ravaging the system. The other big difference is that, you know, as I talked about it, the scientific method was such an important part of Medicine 2.0, and with it came something that I'm sure you've talked about many times, which is the randomized controlled experiment. This is the tool that allowed us to do that thing that Feynman described. The randomized control experiment is really wonderful. It is insufficient by itself to solve the problem. So Medicine 3.0 needs to go from what we call evidence-based medicine. You only do what the randomized control trial says to evidence-informed medicine, which is you take the insights from the randomized control trials, but you have to then modify them and specify them to a given patient.

   19. TFTim Ferriss34:14

       Mm-hmm.

   20. PADr. Peter Attia34:14

       So those are really the huge leaps that we have to kind of take to now make this

6. 34:20 – 37:28

   Randomized control trial results: guidelines, not gospel.

   1. PADr. Peter Attia34:20

      next transition.

   2. TFTim Ferriss34:21

      Could you say a bit more, expand a bit, or give an example, hypothetical or otherwise, of moving from the s- I don't wanna say soul, but extremely strong focus on only making decisions for patients based on RCT data to what you're describing.

   3. PADr. Peter Attia34:43

      Exercise is a great example. So, you know, exercise would say, okay, the, you know, the recommendations would be to... I'm gonna give you two examples, by the way. So this one's kind of a, a simpler one and then a more nuanced, sorta nerdier one. But the nameplate recommendation around exercise is something to the effect of like, you know, two and a half, three hours a week of moderately vigorous activity. But no one is, like, parsing these data down and actually looking at what metrics matter. Like, how much strength do you need to have the absolute lowest risk in mortality? How much cardio respiratory performance do you need to absolutely lower your risk literally fourfold relative to someone in the bottom quartile? So do I have a randomized controlled experiment that tells us that? I don't, right? No one's going to do that experiment, which is I'm gonna take a group of, you know, 10,000 people, randomize them to different levels of training, increase each of their fitnesses to relative levels, and follow them prospectively for the remainder of their lives. That experiment can't be done.

   4. TFTim Ferriss35:50

      Never gonna happen. [chuckles]

   5. PADr. Peter Attia35:51

      Right. So instead, we have to be able to triangulate between these other sources of data. Another example, maybe a bit more glitchy, might be, you know, the way we might use different forms of lipid-lowering medication. So this is kind of a whole other tangent we could potentially dive into, which is if you're really interested in preventing heart disease, which by the way, number one cause of death in men and women in the United States and in the world. So it's sort of, it's the four for four champion of death.

   6. TFTim Ferriss36:25

      [chuckles]

   7. PADr. Peter Attia36:27

      It's such the champion of death, right, that for every woman who dies of breast cancer, there's like eight to 12 women who are dying of heart disease. So pink ribbons matter, red ribbons matter more. This disease would be largely preventable if people didn't smoke, controlled their blood pressure, and had ApoB levels that were equivalent to the levels they had as children.

   8. TFTim Ferriss36:52

      Mm-hmm.

   9. PADr. Peter Attia36:53

      No one will do the clinical trial that will get us there, yet we have all the Mendelian randomization, we have all the mechanistic data. And so an evidence-based approach says, "Look, we're gonna target LDL cholesterol to 100 milligrams per deciliter." This approach is going to say, "Actually, that's probably insufficient for this individual because their risks are higher. And by the way, their appetite for reducing the risk of this disease is higher, so we're gonna take a more aggressive posture," even though the recommendation in the literature is going to be, uh, far less aggressive.

   10. TFTim Ferriss37:27

       Mm-hmm.

7. 37:28 – 47:36

   Revisiting why and how one should increase their medical literacy.

   1. TFTim Ferriss37:28

      So Medicine 3.0 seems to comprise a number of different elements, one of which is early intervention, or certainly much earlier intervention, hence Early Medical, I can only imagine. And another is medical literacy and a more perhaps proactive approach to education and intervention on the part of the patient, right? So it's not a passive experience of being shepherded through a system by a doctor or a team of doctors. You take a much more active role. And I wanted to chat about medical literacy because what I've noticed, just to give personal example, long ago wanted to potentially become a doctor and certainly became fascinated by competitive sports and performance enhancement, and that led to doing my best to read studies and dig into the science and understand as much as possible. I was, I was unsure of the value of that once I shifted courses and decided to do other things. But in the last, I would say, decade, as my parents have gotten older, as more and more of my friends have run into issues, it is astonishing how valuable this minimum effective dose of medical and scientific literacy has become. I mean, it's, it's astonishing how much it helps you to navigate things and make decisions and parse signal from noise. So I'd love for you to speak to medical literacy and how one can become more medically/scientifically literate. And certainly I would highly, highly recommend, I'll just double down on this, that everybody read this book because I think that your book does a good job of this. Very, very good job. And I'll just add a, maybe a sidebar note so I can hear myself talk a little more, which is that there's a, I think, a very common trend among people who are well-educated in some areas, but not in medicine or science, to succumb to a scientism with a capital S, where they'll say, "Well, where's..." Th- they'll know the term randomized controlled trial, and they will only... They will insist that if you say anything outside of the purview of that, that it is unsubstantiated nonsense. And there, there are other examples of this. Or they'll ov- they'll over- they'll over-index on one thing, as you mentioned, right? So pharmacology, it'll be either good or bad, but the fact is, like anything, totally over-indexed, sort of the Paracelsus, the dose makes the poison type of problem. Um, but could you speak to medical literacy? Somebody's listening and they say, "You know what? I recognize that I don't know much about this. I would like to go about it in a really effective way. How do I do it?"

   2. PADr. Peter Attia40:28

      I think you and I have even talked about this once before, Tim, and I, and I don't think I had a great answer for you then, and I don't know that I have a great answer for you now. It's really not a simple thing to do.

   3. TFTim Ferriss40:39

      Mm-hmm.

   4. PADr. Peter Attia40:40

      Let's just start with the nomenclature.

   5. TFTim Ferriss40:42

      Yeah.

   6. PADr. Peter Attia40:42

      My first day of medical school, I still remember one of the professors saying... And I don't remember the numbers, so the story is not as cool 'cause I don't remember the actual numbers.

   7. TFTim Ferriss40:51

      [laughs]

   8. PADr. Peter Attia40:52

      But I'm making the numbers up, but not the point, okay? He said, "Well, all of you are smart hotshots that just graduated the first year class in college. You have an average vocabulary of X words." And X was like whatever number. I don- I honestly don't remember what it was. Call it 20,000 words. He said, "In the next two years," i.e. just in the first, in the pre-clinical phase of medical school, "we are going to add Y words to your vocabulary." And Y was bigger than X by, like, 20%.

   9. TFTim Ferriss41:21

      [laughs]

   10. PADr. Peter Attia41:22

       And those are mostly gonna be Latin, Greek words, by the way. So... And he was right. I mean, it was sort of... It was like learning a new language.

   11. TFTim Ferriss41:29

       Mm-hmm.

   12. PADr. Peter Attia41:29

       So part of it is just the semantic problem. Now, do you have to know all of that? Of course not, right? But, you know, what's proximal, what's distal? You know, all, all of these things kind of factor into this stuff. By far the biggest issue, though, and this is the one that we try to solve the most for on a weekly basis, right? There's a reason, like, you know, that we go to great lengths to write a newsletter every single Sunday. It's basically a class. It's how do we see something in the new... A lot of times it's like such and such a study is published and the news picks it up and writes a take on it that we think is demonstrably wrong. Or a paper gets published that gets a lot of attention that says this, and we think it's an important paper and we wanna highlight it. So we kind of try to use those things as case studies, and I honestly think that's the most efficient way to go about learning this. Now, we did write a series six years ago, I think, called Studying Studies.

   13. TFTim Ferriss42:27

       Mm-hmm.

   14. PADr. Peter Attia42:27

       Which is, I think, a five-part, you know, blog series that Bob Kaplan and I wrote, and I think it's probably a great foundation to just get the basics. What is a case cohort study? What is observational epidemiology? What types of bias exist and how do you look for them? Consider that sort of your basic foundational knowledge set, but thereafter it becomes reps.

   15. TFTim Ferriss42:51

       Mm-hmm.

   16. PADr. Peter Attia42:52

       And the more you can do this ... I think Layne Norton also has a course that he just launched, and I think it's actually called Reps, but I can't remember what Reps stands for. But it's, it's basically a scientific literacy course in how to read studies about nutrition. In his case, it's about exercise and nutrition. Again, we try to cover everything in our newsletter. We'll talk about a drug study, we'll talk about a supplement study, an exercise study, all those sorts of things.

   17. TFTim Ferriss43:15

       Mm-hmm.

   18. PADr. Peter Attia43:15

       So those, to me, are the ways you go about doing this. You just have to dive into it and kind of a, a little bit overcome the fear of it. I, I suspect it's not unlike what you would say if I was asking you, you know, like, "Tim, I really wanna learn Japanese. Is there a particular app that I should look at or this?" I think, I think at the end of the day you'd say, "Look man, you gotta, like, learn it. Like, you just, you gotta, like-

   19. TFTim Ferriss43:38

       [laughs]

   20. PADr. Peter Attia43:38

       ... here's the way to get the foundational skills, and then go and find people to speak Japanese with."

   21. TFTim Ferriss43:43

       Well, let's actually use that example, so learning Japanese, because I do think there are parallels here. I think it, it comes back to objective strategy and tactics, and I just wanted to share a quote that's one of my favorite quotes that also might help folks, which is from Ralph Waldo Emerson. And the quote is, "The man who grasps..." This is of course people, but, "The man who grasps principles can successfully select his own methods. The man who tries methods, ignoring principles, is sure to have trouble." This applies as much in medicine, developing scientific literacy, or learning Japanese, right? It applies in all of these places. And so what I would say, and please feel free to pick this apart, is that to learn Japanese is a very broad objective. So I would encourage someone to refine that substantially, and they might refine it to, "I would like to be conversationally fluent, which means I understand and can convey maybe 80% of what I hear or want to say in a conversation that does not include specialist terminology that is abstract, like economics or art," fill in the blank, right? So you're discussing what happened to whom when, "I was born here, I went to school there. I have two brothers," whatever it might be. And with that goal, then I would say for the vast majority of people, if, and this is a big if, they were willing to make it a part-time job, let's just say with three or four hours per week spread across four consecutive days, that if they layered things properly within three to six months, if they then added in a couple of kind of larger sessions for bulk memorization, and you can use spaced repetition tools, but the tools don't matter as much as being really clear on the objective, that you could become functionally fluent, conversationally fluent as I described it, which omits reading and writing completely in Japanese scripts-

   22. PADr. Peter Attia45:57

       Mm-hmm

   23. TFTim Ferriss45:57

       ... probably within three to six months if you took it super seriously. And there are some adjuncts I would add to that. So to give people maybe a glimmer of hope on the medical literacy side, I would say if people started with your AMA number 30, this is episode 188, how to read and understand scientific studies. If people listen to that first, and assume, folks, before you listen to it, that you're not going to understand at least 30%. Let's just make that an expectation so you don't get frustrated. And if they further maybe read some of the case studies from your newsletter, made that sort of one of the hours that they spend per week, just like the Japanese. If they maybe read a book like Bad Science by Ben Goldacre, who's an MD, British, so some of the cultural context and examples may not resonate for US readers, but he runs through some of the basics. And they read Outlive, that making this literacy your part-time job, a very light part-time job, for three months is one of the best investments you will ever make in your life. I mean, I just, I really feel like the payoff is so tremendous that [laughs] it's, it seems almost crazy to not learn. And you don't have to learn 100,000 words, but you need to be familiar with, let's just call it a few dozen concepts. You'll be able to look at PubMed or databases of studies, or at least abstracts, not going into all the supplemental stuff, and make some sense of A, B, or C.

8. 47:36 – 50:02

   Avoiding scientific method misconceptions.

   1. TFTim Ferriss47:36

      Are there any suggestions you would have for just becoming familiar for, with what the scientific method actually entails, right? So I could think read the Wikipedia entry as a starting point, but for instance, where a lot of smart people, or seemingly smart people, screw up with the scientific method is your guess, although it is a guess, AKA the hypothesis, needs to be falsifiable, right? [laughs] And a lot of people start with completely impossible to falsify guesses, and you're painting yourself up shit's creek [laughs] without a paddle. Any suggestions for how people could at least become familiar with, like, the scientific method and what that means as far as structured thought and process?

   2. PADr. Peter Attia48:19

      I don't off the top of my head have a resource that I can point to. I agree with you that there's so much more nuance to it than just understanding kind of the caricatured version that I explained earlier. For example, how you design an experiment is essential. So even if you have a hypothesis that can be falsified, if you design the wrong experiment to test it, you can miss out. Mm-hmm. This becomes very important, by the way, as you start to look at studies. If a study is, quote-unquote, negative, how do you know if it, it's negative because it was too small in size and what we would describe as underpowered-

   3. TFTim Ferriss48:56

      Yep

   4. PADr. Peter Attia48:56

      ... versus it was adequately powered, but there was no effect? At the other end of that spectrum, sometimes a study will find a statistical significance, but it was overpowered and that difference, while statistically significant, is clinically irrelevant.

   5. TFTim Ferriss49:11

      Mm-hmm.

   6. PADr. Peter Attia49:12

      Now, that kind of stuff we do cover in the studying studies stuff, but I think what you're describing are these more important heuristics that, truthfully, maybe there is a great book out there, and I'm just ignorant of what that book is that, that kind of goes through this. But that's the kind of stuff that I think you learn with, with practice.

   7. TFTim Ferriss49:30

      Yeah.

   8. PADr. Peter Attia49:31

      And unfortunately, if you're not doing experiments, I mean, a- again, I think I learned most of this stuff not in medicine, but in the two years that I spent at the NIH, where, you know, I was a fellow, but doing research. So I was a, you know-

   9. TFTim Ferriss49:43

      Mm-hmm

   10. PADr. Peter Attia49:44

       ... a, like, a research fellow, not a clinician. That's probably where I learned more than anything about how to do science. And so I think anybody who's been in a, in a lab is just learning that, but it's very informal. You know, it's not-

   11. TFTim Ferriss49:58

       Mm-hmm

   12. PADr. Peter Attia49:59

       ... at least for me, it wasn't a structured thing.

9. 50:02 – 51:21

   Austin Bradford Hill.

   1. TFTim Ferriss50:02

      Yeah. In terms of priorities, I would say, folks, man, I've seen so many people lost in the medical system, especially when they suddenly have a, a serious diagnosis with, with some form of cancer or otherwise, and they are absolutely helpless because they do not have a handful of concepts that they've become comfortable with and just a, a basic set of terminology. So at the very least, look up Sir Francis Bacon. I'm sure there's a biography, an excellent biography out there somewhere, and it will no doubt track the development of the, I guess, Baconian approach. [chuckles]

   2. PADr. Peter Attia50:39

      You know, one thing I'll add to this, Tim, before we leave this topic is also for folks to look up Austin Bradford Hill.

   3. TFTim Ferriss50:46

      Hmm.

   4. PADr. Peter Attia50:47

      So Austin Bradford Hill, a scientist of the kind of middle part of the 20th century, to him we owe the Bradford Hill criteria. So there are, I believe, nine Bradford Hill criteria, which are the criteria that we use to scrutinize observational data.

   5. TFTim Ferriss51:06

      Oh, that's great.

   6. PADr. Peter Attia51:06

      So when you have epidemiologic data, how can you scrutinize them to understand and change your confidence in the likelihood that these data are causal? I mean, causality is one of the most important concepts

10. 51:21 – 55:31

    Observational study versus randomized control trial.

    1. PADr. Peter Attia51:21

       in science.

    2. TFTim Ferriss51:21

       Mm-hmm. Could you also just define observational study versus randomized control trial so that people have that just as an anchor?

    3. PADr. Peter Attia51:28

       Yeah. So an observational study doesn't have an intervention. So you, you can observe things either looking backwards, so things that already happened, you can go back and look at what happened. You can even observe things prospectively, but without intervening. So saying, "Hey, we noticed that, you know, there are a group of redheads over here and there are a group of brunettes over here, and we're just gonna follow them for the next 10 years and see if the color of their hair predicts their life satisfaction." You know, I'm making this up, of course.

    4. TFTim Ferriss51:55

       Mm-hmm.

    5. PADr. Peter Attia51:56

       And so you might get an answer from that and say, "Oh my God, like, the people with red hair were so much more likely to get melanoma. I mean, this is devastating, and it must be that something about red hair is causing skin cancer."

    6. TFTim Ferriss52:14

       Mm-hmm.

    7. PADr. Peter Attia52:14

       "And it must be that brown hair must be reflecting the sun, and those people aren't getting skin cancer." So there's a correlation, right? Do we know if there's a cause there? Do we know if the red hair is causing those people to get more skin cancer than the people with brown hair? The answer is probably not, right? The answer [chuckles] is probably that red hair is associated with fairer skin, and that that's the issue. Because if you really wanted to know if red hair was causal, you would randomize people to different groups and, and you would actually dye the hair in one group one color and dye the hair in the other group another color, and then you would follow them. You see?

    8. TFTim Ferriss52:47

       Mm-hmm.

    9. PADr. Peter Attia52:47

       So what Bradford Hill's criteria allow us to do is look at nine factors, such as the strength of the observation. So what's the actual magnitude of the observation? What's the reproducibility of it? What's the biological plausibility of it? Is there an analogy to it? Is there a dose effect to it? And as you go through these nine criteria, which actually I, I think I actually do this a couple of times in the book, because so much of the data we look at around nutrition and exercise are unfortunately epidemiological. We can't do the controlled experiments. But it's what allows us to say, when I read a study that says 12 hazelnuts will reduce your risk of death, you know, 12 hazelnuts a day in consumption reduces risk of death by 10%, I can look at that and say, "Total nonsense." Like, that's just epidemiologic nonsense. Conversely, when I look at epidemiologic data that say people who are really, really strong live longer than people who are really, really weak, by going through those nine criteria, I can be much more confident that that is actually causal.

    10. TFTim Ferriss53:47

        Mm-hmm. So I, I'll mention two things. The first is if you're gonna get... 'Cause we're mentioning a number of different books, and this is not just to, to blow smoke up Peter's ass, which by the way was a real thing. I found a menu from the Wild West, and it was, like, all these various things you could have done to you, and blowing smoke up your ass was, like, $50. It was the most expensive. So that's a real thing. So it's not just that I'm doing that.

    11. PADr. Peter Attia54:09

        [laughs]

    12. TFTim Ferriss54:09

        But if you're gonna buy one book on this stuff, get Outlive because it covers a broad spectrum. And I wanna also mention, because I think this is really critical, and we'll, we'll probably come back to this, but the, it isn't just about extending lifespan, about extending healthspan and having, like, full optionality physically or trying to preserve that to the greatest extent possible for the longest period of time possible. I will add, though, that people will see, for instance, and a lot of this medical or scientific literacy is so you don't get fooled by misinterpretation or sensationalism in media. Because you'll see a headline that's something like Bananas increase your risk of colorectal cancer by 100%. And [laughs] what that means though, if you dig into the data, is like, all right, your risk goes from one in five billion to two in five billion. [laughs] So it's just like from a behavioral standpoint, it just does not matter at all. There's a book called How to Lie with Statistics by Darrell Huff, which I think is a very fast read, and that will also complement everything that we're talking about. So let's look a little more closely at some of the content and interventions and tools in the book. And

11. 55:31 – 58:35

    Are sleep trackers downgrading the quality of our sleep?

    1. TFTim Ferriss55:31

       I'm not sure this is a great way to, to kick it off, but there's a, an expression I've heard at least applied to medicine quite a few times, which is 50% of what we know is wrong, we just don't know which 50%.

    2. PADr. Peter Attia55:42

       Mm-hmm.

    3. TFTim Ferriss55:42

       And so I'm, I'm curious to know what you have seen kind of peeking behind the veil at what is not working and what you have then designed to address that misfire in your practice and by extension in the book, right? You mentioned a few things, right, like ApoB levels. You mentioned being very specific with exercise prescription, being extremely specific, and the, the possibility of lowering certain types of risks fourfold. So I'll let you tackle that however you want. We can start wherever makes sense.

    4. PADr. Peter Attia56:20

       We could probably talk about different things within different, different buckets. So starting with sleep, right? I think that, you know, with sleep, I kind of like to simplify things a little bit sometimes. So one thing that I think is happening a lot right now is people are getting, probably at least some people, overly anxious about what their sleep trackers are telling them. And so, you know, we've got a problem where the pendulum has sort of swung a little too far to the other side, where, you know, maybe 10 years ago nobody thought at all about sleep, and now you've got a class of people, me among them-

    5. TFTim Ferriss56:57

       [laughs]

    6. PADr. Peter Attia56:58

       ... who maybe think too much about sleep, and all of a sudden it becomes a little bit counterproductive. And we see this-

    7. TFTim Ferriss57:03

       Yeah

    8. PADr. Peter Attia57:03

       ... in a subset of our patients. And the first and most important prescription for those people is stop tracking. Take the tracker off.

    9. TFTim Ferriss57:10

       [laughs]

    10. PADr. Peter Attia57:12

        Let's just focus on the fundamentals. What time are you getting into bed, and what time are you getting out of bed? If we-

    11. TFTim Ferriss57:18

        Mm-hmm

    12. PADr. Peter Attia57:18

        ... can within fifteen to thirty minutes on either one of those completely fix that and completely toggle on the basic blocking and tackling aspects of sleep hygiene, which have to do with food, alcohol, light, temperature, noise, et cetera, I mean, you're gonna be okay.

    13. TFTim Ferriss57:37

        Mm-hmm.

    14. PADr. Peter Attia57:37

        And I don't really need to know what your sleep score is and how many minutes of this, you know, sleep versus that sleep you had. So I personally go through this myself. I'll go through phases of time where I'm not looking at any sleep tracking device. And if I know I'm gonna be in an environment where sleep is compromised, which is basically a lot of the time if I'm traveling, I don't even take a sleep tracker with me. Because why do I need something to remind me of what's probably happening? How about I just do the best job I can and be a little less data focused? So that's an example of where I feel like a couple years ago I would have just said more data is always the answer, and now-

    15. TFTim Ferriss58:13

        Mm

    16. PADr. Peter Attia58:13

        ... I think I'm a bit more measured and I say, "Look, sometimes more data is not always the answer." Now-

    17. TFTim Ferriss58:18

        Yeah

    18. PADr. Peter Attia58:18

        ... the flip side of that is there's nothing that will demonstrate to a person how much late night food and alcohol are ruining their sleep than a sleep tracker. So I do think it's really valuable to see that.

    19. TFTim Ferriss58:28

        Mm-hmm.

    20. PADr. Peter Attia58:29

        For many of my patients, that has been the most decisive thing that has reduced their alcohol

12. 58:35 – 1:02:15

    Under what conditions does Peter feel alcohol might be worth its downsides?

    1. PADr. Peter Attia58:35

       intake.

    2. TFTim Ferriss58:35

       Oh, for sure.

    3. PADr. Peter Attia58:36

       And despite what a lot of the epidemiology will tell people, alcohol is not good for you in any dose. Doesn't mean we shouldn't drink it at all, but let's not delude ourselves into thinking it's actually healthy at some low dose. It's not. So-

    4. TFTim Ferriss58:47

       [laughs]

    5. PADr. Peter Attia58:47

       ... understanding that it's a toxin, I hope you have a more measured response. You know, my response to alcohol, while we're on that topic is, if I drink something that doesn't taste incredible, I pour it out. Like-

    6. TFTim Ferriss58:58

       Yeah

    7. PADr. Peter Attia58:58

       ... I'm never gonna tolerate a bad glass of wine, ever. It's just not worth it.

    8. TFTim Ferriss59:03

       So since we're on it, I'm gonna, I'm gonna pull us back to this question of data probably through the lens of continuous glucose monitors and the best uses and maybe the most common misuses for people who do not have, you know, type 2 diabetes or, or type 1 diabetes. But let's just sit with the alcohol for a second. So what are your personal rules for alcohol consumption outside of the if it tastes mediocre or shitty, it gets poured out, which is a great rule. But what are your favorite types of alcohol? How do you personally navigate that?

    9. PADr. Peter Attia59:41

       Well, I'll start with like kind of quantity. I would personally just say there's gotta be an insane reason to have more than two drinks in a day.

    10. TFTim Ferriss59:50

        Mm-hmm.

    11. PADr. Peter Attia59:51

        So it's somewhere between zero and two, and it's gotta be a really good reason to drink on more than three days a week. So in the back of my mind, I'm keeping a tally, which is I really shouldn't be having more than about seven drinks in a week.

    12. TFTim Ferriss1:00:04

        Mm-hmm.

    13. PADr. Peter Attia1:00:04

        And again, seven drinks in one day is very different than one drink a day for seven days. So it's the frequency and it's the dose, and that defines the poison. The second thing is I really have to make sure that that drinking is a good three hours away from sleep. Again, when I say these things, people say, "Peter, you must be a robot." No, I'm just saying these are general principles. There are going to be times when I violate that. I think I posted something on Instagram a little while ago, which was like the most rancid night of sleep. I mean, my sleep data were comically bad. And the reason was we had friends over. It was very late. We drank. We ate. You know, I basically went to bed. They, you know, by the time they left at like 10:30, I went to bed and we had just finished eating sort of thing, and not surprisingly, my sleep sucked. The point I made in the post was I'd do it again. It was a fantastic night. Our friends and, and the four of us hadn't had dinner together in a long time. So- You just have to be very thoughtful and deliberate about the choices and trade-offs that you make. As far as the type of alcohol, you know, I think people, I think, love to... This is, again, an example of something I think we tend to over-index to. Oh, you know, I drink a lot, but let me tell you, it's just vodka and tequila, so it's got to be good for me, right? It's like, no, alcohol is alcohol, right? So I love tequila. I love mezcal. I love really good wine, and I love really dark Belgian beer. I'm not deluded to think that any of those are healthy. And I know that there are some people who have, you know, a horrible reaction to certain types of alcohol. Well, I would put that in the same category as people who have a horrible reaction to certain types of foods. Don't consume them. But I think mostly where I focus, Tim, is on how much am I going to drink? How close is it going to be to bed? And what's the total tally per week and never exceed a certain tally in a given day?

    14. TFTim Ferriss1:01:52

        You know, I was waiting for the right time to bring this up, Peter, but you know, I know that people say cookies are bad for you, but I've only been eating Nutter Butters, and I feel like [laughs] I'm kidding. I feel like that's the equivalent, although it's less of a neurotoxin.

    15. PADr. Peter Attia1:02:07

        I do love Nutter Butters, by the way.

    16. TFTim Ferriss1:02:08

        They are good. They're so good.

    17. PADr. Peter Attia1:02:10

        I don't know the last time I had one, but oh my God, now that you reminded me of that, that's horrible of you to do that.

    18. TFTim Ferriss1:02:14

        [laughs]

13. 1:02:15 – 1:14:22

    Continuous glucose monitors (CGMs).

    1. TFTim Ferriss1:02:16

       So, well, that'll, that'll combine nicely with the CGMs. So all the GBs and the CGMs. So could you... [laughs] Inside joke. Could you speak to continuous glucose monitors? Because for a long time, for, I mean, even still now, these are broadly thought of as something that one might only use if they have some form of diabetes. However, there are people who do not fit in those categories who use them, and I would love for you to just perhaps give us a, a bit of an overview on CGMs and, and what you have seen as the best uses and how you use them in your practice.

    2. PADr. Peter Attia1:02:57

       So a continuous glucose monitor is a device. There are really two big ones on the market right now. One is made by a company called Dexcom, and one is made by a company called Abbott, and the latter is called the Freestyle Libre. So I think it's a company that Abbott acquired many years ago. These are devices that are worn usually on the tricep. They can also be on the abdomen. And they have a little tiny filament that is quickly shot in with a needle into the subcutaneous space. So the filament remains after the needle comes out, and the filament sits in a part of the body where it can sample something called interstitial fluid. This is basically the fluid between cells. To be clear, it's not sampling the blood. So it samples the interstitial fluid, and it measures glucose level there, and it's basically calibrated to know based on what the reading is there, what the glucose level is in the blood. So a continuous glucose monitor, as its name suggests, is a way to give you real-time information about what your blood glucose is. As you said, for people with type 1 diabetes, which was the first use case, this is a very important innovation because people with type 1 diabetes are by definition dependent on insulin. So they are using insulin exogenously to do the job of their pancreas, which is no longer working. And the pancreas, of course, is like this brilliant organ where it's the one that's auto-regulating glucose via insulin. And when that goes away, they have to be the one to do it. So now they have this device that is at least giving them real-time glucose information, and they can adjust insulin injections as needed. It obviously didn't take long for that to expand into a much, much larger market, i.e. 10 times the size, which is people with type 2 diabetes, some of whom do require exogenous insulin, some of whom do not, but all of whom by definition have a carbohydrate and glucose tolerance disorder, right? The very definition of type 2 diabetes is based around unregulated peripheral glucose. And this tool is therefore helpful, right? It's helpful in, first and foremost, I think, knowing what to eat. You know, I think historically we have given people with type 2 diabetes abjectly horrible news and insight with regard to what to eat. You know, I mean, we just haven't really helped them think through this problem. So the CGM makes it pretty clear that not all foods are created equal when it comes to managing glucose homeostasis. So everything I've said so far is relatively straightforward. I think where we now... And this is a great example, by the way, of Medicine 3.0 versus Medicine 2.0. So everything I've said so far more or less makes sense if you're in Medicine 2.0. In fact, I think we're finally at the point where even Medicine 2.0 is starting to accept the fact that carbohydrate restriction is a really good idea for people with type 2 diabetes. It's not the only way, by the way. So caloric restriction in general will work to improve insulin sensitivity, which therefore improves glucose regulation. But it does seem that carbohydrate restriction as a form or a gateway to caloric restriction has greater efficacy than other methods. Once we now talk about people without diabetes, Medicine 2.0 would argue a CGM plays no role. Okay. Is there a randomized control trial demonstrating the efficacy of CGM in anything outside of patients with diabetes? There is not. But now we have to get into the leap of faith that one takes when you start triangulating between other pieces of data. So we want to start with one, which is in a population of non-diabetics, is there any evidence that glucose levels matter? So type 2 diabetes is defined as having a hemoglobin A1c above 6.5%. Hemoglobin A1c is just a way to measure how much glucose is stuck to hemoglobin, and by knowing what that number is, you can impute what the average blood glucose is in that individual over the preceding three months. So 6.5, which is the cutoff, translates to an average blood glucose of 140 milligrams per deciliter. So the question then would be, if you take two people who don't have diabetes, one of whom has a hemoglobin A1c of 5.0, and one of whom has a hemoglobin A1c of 6.0, neither of them are diabetic, is there any difference in their outcomes? So to put that in perspective, the guy at 5.0 has a average blood glucose of about 100 milligrams per deciliter. The person at 6.0 has an average blood glucose of about 120 milligrams per deciliter. So they're both outside that diabetes range. Well, the answer here is actually pretty clear. It is that there is a difference. In fact, for a non-diabetic population, the lower the average blood glucose, as estimated by hemoglobin A1c, the lower the all-cause mortality. Okay, so what's the implication now? Well, if the implication is if you take a group of people who don't have diabetes but want to live longer, i.e., they want to lower their risk of cancer, they want to lower their risk of cardiovascular disease, they want to lower their risk of neurodegenerative disease, I think we can make a pretty reasonable leap of faith that having a lower average blood glucose is better than having a higher average blood glucose, even if that higher average does not put you in the range of a diabetic. So now the question becomes, are there tools to help us manage that? Because the one tool would just be the A1c. You could say, "Well, I'm just gonna get my hemoglobin A1c measured every six months." The problem with that, as we know, is that hemoglobin A1c is very easy to mislead. It's very dependent on red blood cell turnover. So the more rapidly red blood cells turn over, the more artificially low the hemoglobin A1c will be. And conversely, the longer the red blood cell sticks around, the higher artificially the hemoglobin A1c will be. And it's for that reason that we like to use CGM to actually get true measurements of average blood glucose. When a patient who doesn't have diabetes puts on a CGM for the first time, they're invariably surprised. There's this real learning phase that comes. You've done this, Tim. You were doing this probably 10 years ago. You wore your first one. Everybody goes through this. I remember, you know, for me, it's been about eight years since I started. At first, you simply cannot believe the things that drive your blood glucose up.

    3. TFTim Ferriss1:09:45

       [chuckles] Could you give some examples?

    4. PADr. Peter Attia1:09:47

       Yeah, I mean, like I, I, if I remember the first time I had Raisinets, I was like, it's not like I didn't expect it to go up. I didn't expect it to go up like that, right?

    5. TFTim Ferriss1:09:55

       Mm-hmm.

    6. PADr. Peter Attia1:09:56

       Exercise, certain forms of exercise. And by the way, I'm not saying this is pathologic. There's nothing wrong when you're exercising for your glucose to skyrocket if you're doing Tabatas or you're doing HIIT workouts. It's, again, it's not pathological, but it's super interesting. And other things that I think are pathological is how much your blood glucose goes up if you had a poor night of sleep.

    7. TFTim Ferriss1:10:19

       Hmm.

    8. PADr. Peter Attia1:10:20

       You know?

    9. TFTim Ferriss1:10:20

       Yeah.

    10. PADr. Peter Attia1:10:21

        If you have a horrible night of sleep, your insulin sensitivity gets crushed the next day and your glucose levels go up. Well, that's actually very interesting. And that, you know, again, maybe you could argue that adds too much stress to the fire, but it's an, it's an insight nevertheless that can help drive a behavior change. I think in the book I cover kind of my 10 best insights from years of CGM in myself and patients. It's about different foods and, like, foods high in fiber are gonna have one effect, lean sources of protein versus fatty sources of protein, all those sorts of things. Ultimately, I think CGM becomes a really helpful tool for compliance. It becomes a behavioral tool. We tend to gamify it a little bit. I know that when I'm wearing CGM, which I just happen to be right now, by the way, I'm gonna think twice before eating something stupid. And again, it's purely just because my personality likes to gamify things, right? It's like, yeah, I'm tempted to go and eat all the leftover waffles on my kid's plate.

    11. TFTim Ferriss1:11:19

        [chuckles]

    12. PADr. Peter Attia1:11:20

        But I just know it's like, eh, it's gonna shoot my blood glucose up, and I like not doing that. Where I think people get into trouble and where the counterargument is, which is a fair argument, is, look, if you only index on blood glucose, you could still end up doing a bunch of things that aren't healthy, you know? If you ate bacon for every meal every day, your blood glucose would not go that high, but it's probably not the healthiest choice, and I would agree with that. But by that logic, we shouldn't look at body weight either, because by smoking cigarettes, your body weight will go down. So does that mean body weight is a lousy measurement? No. It just means that any measurement in isolation can be ridiculous and can be gamed. So we shouldn't ignore blood glucose any more than we should ignore body weight or body fat or body composition. We just have to understand that it's one of many tools that we can look at. And the CGM, again, do I think this is, like, necessary to live a longer, healthier life? Of course not. It's simply one tool that we have to help us understand how to regulate one of the, you know, four macronutrients.

    13. TFTim Ferriss1:12:34

        So I'd like to just add two things to that. So the first is people listening who have not experienced a CGM may hear puncture filament and imagine something out of, you know, Hostel II or something like that. I will say that in 2008, I want to say, was the first time I used a Dexcom, which was the size of [chuckles] like the cellphone used by Gordon-

    14. PADr. Peter Attia1:12:56

        Like a baseball

    15. TFTim Ferriss1:12:56

        ... Gekko in Wall Street. It was huge. And the experience of putting what felt like to me subjectively kind of barbecue tongs into my abdomen was very unpleasant at the time. I have, however, tried the latest generations, and you basically feel nothing. I mean, it's so easy in my experience. I mean, I don't know how many of your patients report a lot of pain with that, but I was shocked by how completely innocuous the whole procedure was. I mean, it was very, very mild, very quick, very easy. So I just wanted to mention that. And then secondly, this is probably applies more to your patients than to you, but in the book you mention the Hawthorne effect, which I think was first coined in manufacturing and looking at worker-

    16. PADr. Peter Attia1:13:48

        Yeah

    17. TFTim Ferriss1:13:48

        ... effectiveness or output. But that is the phenomenon whereby people modify their behavior when they're being watched, right? So I, I think that is another selling point for some form of accountability. Is there anything you'd like to, like to add to that?

    18. PADr. Peter Attia1:14:04

        There are some patients of ours who actually want to utilize the Hawthorne effect, and if we agree mutually to do so, we can see all their data. So they can just say-

    19. TFTim Ferriss1:14:14

        Yeah

    20. PADr. Peter Attia1:14:14

        ... "Look, I want you to be looking at my CGM data every day, and that's going-- you're an accountability partner for me, so I'm gonna eat less junk food."

14. 1:14:22 – 1:21:25

    Underutilized metrics and tools for expanding health and lifespan.

    1. TFTim Ferriss1:14:22

       Mm-hmm. So what are some of the other perhaps underemphasized or underutilized metrics that you think are important? This could be in the realm of metrics or tools, right? So it could be forms of screening, it could be blood markers of different types. There are a few that come to mind that I imagine are on this list. Could be physical performance, markers of some type. What are some that come to mind?

    2. PADr. Peter Attia1:14:56

       If we're gonna just talk in magnitude, VO2 max and muscular strength stand in a league of their own.

    3. TFTim Ferriss1:15:05

       Hmm.

    4. PADr. Peter Attia1:15:05

       So there's really nothing that's within the zip code of those two metrics. So having very, very high VO2 max for your age and sex and being very strong, I mean, again, they have more of a positive impact than any single thing we can think of has a negative impact. And that includes having end-stage renal disease, like being on the wait list for a kidney while you get dialysis, being a smoker, having high blood pressure, having type two diabetes, being obese. The downside of those things is relatively small compared to the upside of having a high VO2 max and being very strong. So we almost shouldn't even talk about things until people are willing to accept that fact and take the steps necessary to address them. Now, you might say, "Well, okay, how many people can become very, very strong or have a very high VO2 max?" And the answer is, I don't know. Like, I don't know, especially on the VO2 max side, you know, to get into that top two point five percent of the population where you really start to see an enormous gap between you and everybody else in terms of lifespan, yeah, maybe, maybe only a quarter of the population has the potential to get there. But the point is, everybody has the potential to be more fit than they are, you know, outside of people who are already doing everything they can. And so just going from being in the bottom twenty-five percent of the population to the twenty-fifth to fiftieth percentile of the population cuts your risk of all-cause mortality in half at any point in time.

    5. TFTim Ferriss1:16:43

       Hmm.

    6. PADr. Peter Attia1:16:44

       There's nothing that compares to that. Like, there's no drug out there that's gonna do that. So again, I think you could talk about drugs all day long and how I think they're really important and how we could think about controlling ApoB and, you know, rapamycin and metformin, all these other things. All that stuff is, you know, it's, it's pixie dust compared to what these things are. On the strength side, the same thing. Anyone who's got older parents knows this. If you really wanna watch somebody suffer when they're aging, you watch them losing their cognition and you watch them losing their physical body. You watch them lose the ability to move around with ease, to, to have balance, to be pain-free, all of these things. Well, a big part of that is being strong. You know, strength is something we can actually hang on to as we age. You know, we lose quickness long before we lose strength, and, you know, that's, that's the good news. The bad news is it-- you have to be very deliberate in how you train it, right? So I'm sure on the podcast you've discussed type one and type two muscle fibers, so people are probably familiar with that.

    7. TFTim Ferriss1:17:51

       Why don't you reiterate that?

    8. PADr. Peter Attia1:17:53

       So we basically have, you know, our muscles are made up of these fibers. They're very unique properties. So muscles are these multicellular things where the, the cells are these long sort of fibers that contract past each other, and that's what con- creates the, the contraction of a muscle. But if you dig a little bit deeper, you have different types of fibers. So you have type one fibers, which are fueled mostly, if not entirely, by an aerobic process. So they can use fat, they can use glucose, but they do so in the presence of oxygen primarily. They're very slow to fatigue, which is mostly where the name comes from, but they don't generate that much force. So these are the muscle fibers that are mostly on display when you're, you know, walking or just carrying out activities of daily living.

    9. TFTim Ferriss1:18:44

       Right. Commonly called slow twitch, as you alluded to. Slow twitch muscle fibers.

    10. PADr. Peter Attia1:18:48

        Correct. Yeah. So you can do things for a long period of time, and these things don't fatigue. Conversely, another subset of these fibers are type two fibers, and they're called fast twitch muscle fibers, and they're fast to fatigue. Now, they're much more powerful. So when a type two fiber contracts, far more is happening. You know, it's generating far more force, but it's doing so with a different metabolic strategy, so it's glycolytic. It's just using glucose or, you know, broken down glycogen. And it's going to fatigue quickly. So it's accumulating metabolic byproducts that are leading to fatigue. So there's a reason why if I say, "Tim, jump up and down as high as you can as many times as you can," this is not gonna be a long exercise.

    11. TFTim Ferriss1:19:32

        Right. [laughs]

    12. PADr. Peter Attia1:19:32

        We don't have to sit and wait two hours for you to finish that. You're gonna fatigue pretty quickly if you're doing maximal jumps. Whereas if I say jump rope, you could do that for 30 minutes easily, and if you're, you know, a relatively fit person. So you get the sense of the difference. Now, as we age, we lose power and explosiveness more than anything else, and we lose that the soonest, and that's due to the type two fiber, the atrophy of the type two fiber. And this, again, this comes back down to strategy, so that's why if you wanna live a longer, better life, you have to have a strategy in place for maintaining type two fibers.

    13. TFTim Ferriss1:20:09

        Mm-hmm.

    14. PADr. Peter Attia1:20:09

        And you're not going to get that without resistance.

    15. TFTim Ferriss1:20:13

        Yeah.

    16. PADr. Peter Attia1:20:13

        You won't ... You know, you can't say, "Look, I, I play tennis every day. I walk every day." Those things are great. They're not doing something for your type two fibers.

    17. TFTim Ferriss1:20:22

        Yes. Let me hop in for a second 'cause I want to get specific on that, because I think some of the approaches or tools might be counterintuitive for folks. So first, just some random trivia for folks who might be interested. If you've ever carved a chicken or a turkey, neither of those like to fly very much, and [chuckles] the breast meat tends to be white, and then you have the dark meat. Well, there you have sort of type two, type one fibers respectively, so just a ... for the next time you're cutting up a bird.

    18. PADr. Peter Attia1:20:52

        Yeah, the reason the legs are dark is they have much more mitochondria. Those are-

    19. TFTim Ferriss1:20:56

        Mm-hmm

    20. PADr. Peter Attia1:20:56

        ... their slow-twitch muscles there that are, you know, heavily dependent on oxygen delivery and oxidative phosphorylation, whereas the white meat, the breast meat, is very fast twitch, quick, quick, quick, quick flapping.

    21. TFTim Ferriss1:21:10

        Mm-hmm.

    22. PADr. Peter Attia1:21:10

        Doesn't have the mitochondria, so that's ... you know, has far less of it, and therefore that's kind of a less oxygen-rich muscle. When you dissect us, of course, you don't see that difference. Our type one and type two fibers are less clearly separated.

15. 1:21:25 – 1:30:05

    Strength.

    1. TFTim Ferriss1:21:25

       Mm-hmm. So if, if someone wants to improve strength, correct me if I'm wrong, but you have a number of maybe ... They're not just heuristics. I mean, they're direct indicators, but you have a number of things that you focus on, and I'm sure there are many others, but in the strength category, I would love to know how you define very strong, and perhaps this would be a place to talk about or at least include hand strength, farmer's carry, or, or anything else that you'd like to, to add that might not immediately show up on someone's kinda mental radar when they're thinking of strength.

    2. PADr. Peter Attia1:22:04

       Yeah, I mean, there are a handful of strength categories that we think really matter and, and just ideas that are important when you think about strength. So one of them is the importance of understanding eccentric versus concentric strength and how both are very important. I, I actually put something up on Instagram the other day about this where I, you know, just explained that the concentric phase is basically the go and the eccentric phase is the slow. So you accelerate through concentric force, which is the force a muscle generates as it is shortening. That moves you forward. The eccentric phase, which is equally important but oft ignored, is the strength or the force that a muscle is exhibiting as it is lengthening. That's what's decelerating. That's what's slowing you down. Andy Galpin, I think, recently talked about a great metric, and I agree. This is a fantastic metric. Something, you know, I'll, I'll check mine constantly is how far a broad jump can you do? So I wanna make sure that I can do a standing broad jump that's higher than my height laying down. So, you know, if I'm 5'10", I wanna make sure I'm jumping at least six feet on a broad jump. And a broad jump's a really interesting test. It's a profoundly extreme example of concentric and eccentric strength in the same movement. If you're just standing there and you wanna jump six feet in front of you, that requires an enormous explosion. That's a very high concentric load. But guess what? If you wanna not break your nose when you land and destroy your knees, you better be able to decelerate yourself and slow yourself down. That's an unbelievable eccentric ask. So while that's a very extreme example, consider walking up and down stairs. Walking up the stairs is very taxing concentrically, but where do most people get hurt in life? It's actually walking down stairs. And if you watch, especially as people age, the difficulty they have in slowing themselves down when they're coming down stairs or taking a step off a curb, this is where people are falling and breaking their hips. It's far less that they're falling due to concentric weakness and far more that they're falling due to eccentric weakness. So therefore, principle number one in our strength training is always be doing both, not necessarily in the same movement, not necessarily focusing equally on a given day, but everything we wanna do, we wanna make sure that we are hitting the concentric and the eccentric phase, not just-

    3. TFTim Ferriss1:24:42

       Mm-hmm

    4. PADr. Peter Attia1:24:43

       ... the more obvious, which is the concentric.

    5. TFTim Ferriss1:24:46

       Now, does that take the form of simply accentuating the lowering in the case of, say, a trap bar deadlift or something like that where you have something like two seconds up, four seconds down, or does it take other specific forms?

    6. PADr. Peter Attia1:25:01

       There are very specific exercise that you'll do. So for example, like a, you know, a Nordic rollout, you know, a Nordic fall, you know, for a hamstring exercise where you're-

    7. TFTim Ferriss1:25:08

       Mm-hmm

    8. PADr. Peter Attia1:25:08

       ... you know what I'm talking about, when you're kneeling on a mat and your feet-

    9. TFTim Ferriss1:25:11

       I do

    10. PADr. Peter Attia1:25:12

        ... are held in position and you sort of allow yourself to slowly come down. That's just purely-

    11. TFTim Ferriss1:25:16

        Yeah

    12. PADr. Peter Attia1:25:16

        ... eccentric misery.

    13. TFTim Ferriss1:25:17

        Requires quite a bit of ... starting strength to do.

    14. PADr. Peter Attia1:25:21

        Well, and, and truthfully, we wouldn't have people do that out of the gate. You'll do that with assistance to start, because most people simply don't have the hamstring strength to do that. Yes, it can be accomplished greatly by using slow, what we call negatives.

    15. TFTim Ferriss1:25:35

        Mm-hmm.

    16. PADr. Peter Attia1:25:36

        So focusing just as much on the negative as the positive. So for example, one of my favorite exercises to do are step-ups, because, one, it's a single leg exercise, it's a beautiful hip hinge, and we can talk about it in some detail in a moment, 'cause hip hinging is another one of the big principles, and it allows you to do a very nice isolation of the eccentric on the step-down.

    17. TFTim Ferriss1:26:00

        Mm.

    18. PADr. Peter Attia1:26:00

        And you really have to be able to control that. If you can't control it, you're using too much resistance, obviously. So hip hinging is another big, important principle.

    19. TFTim Ferriss1:26:09

        Mm-hmm.

    20. PADr. Peter Attia1:26:10

        And again, hip hinging, when people think about that, they think that, does that have to be a squat or a deadlift? No, it doesn't have to be. It can be a hip thruster, it can be a lunge, it can be a step-up. I mean, I think the step-up might be the single most important one for people to do because it doesn't have any axial loading.

    21. TFTim Ferriss1:26:24

        Could you explain what you mean by that?

    22. PADr. Peter Attia1:26:26

        When you're doing something like a squat or a deadlift, by you ... There's, there's weight that is basically pulling your spine down to your hips.

    23. TFTim Ferriss1:26:35

        Mm-hmm.

    24. PADr. Peter Attia1:26:35

        In the squat, it's because the weight is actually sitting there. In the deadlift, it's because the weight is being, the force is being transferred through your arms there. But in either case, you are loading the axis of your spine. And that's fine if you know how to do it safely, but as, you know, you know, having done these things, like, that's not just something you can walk in off the street and do. You really have to be coached how to do that stuff safely. And, you know, stepping up onto a block is something that's much safer to do.

    25. TFTim Ferriss1:27:06

        Mm-hmm.

    26. PADr. Peter Attia1:27:07

        And it's also something that you can do with a single leg at a time, and therefore you get to see what your asymmetries are, because we all have them. I mean, I am so deep down the rabbit hole of step-ups that I can't even, like, explain the nuances in oblique compression, pelvic angles, and the difference between when my left and right leg do it. But it, you know, tinkering with that stuff allows me to work out so many kinks with, with how my body works. You mentioned another one earlier, which is being able to carry heavy things. You know, this is just such an essential skill for our species. It's something that we do better than anything. There is no animal that can carry with their hands what we can do. Certainly a strong male, but even a strong female can carry their body weight in their hands. You know, half their body weight in each hand is not, is not an insurmountable ask for us.

    27. TFTim Ferriss1:28:00

        Would that be a hypothetical target for your patients?

    28. PADr. Peter Attia1:28:04

        Yeah. We would like to see our patients carry half their body weight in each hand for a minute.

    29. TFTim Ferriss1:28:09

        For a minute.

    30. PADr. Peter Attia1:28:09

        So walk around with half your body weight in each hand for a minute. Yeah. And having strong hands is, you know, it, it's, it's one of the most correlated findings with longevity. So we talked earlier about, like, what does it mean to be really, really strong? Well, unfortunately, the data on this are based on what the studies show, and the studies are testing, you know, interesting things, but they're not exhaustive, right? So they're usually looking at grip strength, leg extension, bench press are the most commonly tested things. But grip strength comes up over and over and over again in studies as such a proxy for longevity. You know, lower risk. I think there's a figure in, in my book that talks about the unbelievable monotonic decline in both the risk of onset of dementia and death from dementia as grip strength increases.
16. 1:30:05 – 1:35:22

    Rucking around and finding out about VO2 max.

    1. PADr. Peter Attia1:30:05

       more.

    2. TFTim Ferriss1:30:05

       What does your protocol methodology look like for rucking?

    3. PADr. Peter Attia1:30:09

       So I use 55 to 60 pounds, and I'll typically do an hour ruck. And because of where I live, it's really hilly, so I really like that. Going up the hills, I'm going hard. You know, I'm really pushing my cardio up the hills, and I'm trying to find the steepest hills possible to come down because that's working that huge eccentric gear. It's really forcing me to be able to decelerate on the way down those hills with a lot of weight. And you're not getting the pounding. I mean, I think that's the beauty of it, right? Is you're not pounding your knee with the impact you would if you had to run to produce that effect.

    4. TFTim Ferriss1:30:43

       Yeah. That's probably the most compelling reason that I started rucking a few years ago, and especially in, in preparation for, for certain alpine hunts and so on. I did a ton of rucking, and the collateral benefits, I mean, they're not really collateral, I mean, the direct benefits were this sort of holy shit effect that sometimes I've seen with kettlebell swings and other things, where this translation that you wouldn't expect pops up in all sorts of ways. And I used to be a runner, but I ended up ... You probably didn't know this, but I used to be a cross-country runner when I was, say, up to about age 15, and then through poor choices like doing lots of wrestling and other impact sports, developed knee issues, and so stopped running. But I always missed the sensation of getting a good workout while walking or, or moving in some fashion on ground, and rucking solved that. Coming back to VO2 max, so VO2 max, I've always wondered to what degree someone can improve VO2 max. You already spoke to the benefits even if you're moving from, say, 25th percentile to 50th percentile. Huge benefit, right? I mean, I think you said halving certain mortality risks. What have you found to be the best approaches for improving VO2 max?

    5. PADr. Peter Attia1:32:03

       Well, first off, it can actually be improved quite a bit. I think the research out there understates how much it can be improved because the research studies are relatively short.

    6. TFTim Ferriss1:32:13

       Mm-hmm.

    7. PADr. Peter Attia1:32:13

       So it's true that in a 12-week study you might see, you know, kind of an 8% improvement or a 10% improvement. I would say that's just the tip of the iceberg, right? We're, we're not talking about 12 weeks of training here. We're talking about a lifetime of training, and we're talking about 25, 50% improvement in VO2 max that anybody who's been involved in serious training will see all day long.

    8. TFTim Ferriss1:32:35

       Mm.

    9. PADr. Peter Attia1:32:35

       So the how is also very important. The analogy I like to use, which I'm sort of borrowing from one of my old cycling coaches, is that think about building a pyramid. The VO2 max is the height of the pyramid.

    10. TFTim Ferriss1:32:49

        Mm.

    11. PADr. Peter Attia1:32:49

        So if you want to build a really high pyramid, it also has to have a really wide base.

    12. TFTim Ferriss1:32:57

        Mm-hmm.

    13. PADr. Peter Attia1:32:57

        So the key for building a high VO2 max is saying, "I'm going to spend about 80% of my aerobic training time in zone two." And this is counterintuitive, right? A lot of people think, "Oh, my God, if I want to build a high VO2 max, it has to be all intense training." No, you have to first and foremost build that huge aerobic base. That is the pyramid-

    14. TFTim Ferriss1:33:20

        The foundation

    15. PADr. Peter Attia1:33:21

        ... that allows you to make the peak higher. So once you have that aerobic base, that other 20% of the time is used well above. So basically, most people are training too hard to build the base, but not hard enough to build the peak, so they're in what I kinda think of as garbage training zone.

    16. TFTim Ferriss1:33:39

        [laughs]

    17. PADr. Peter Attia1:33:40

        And, and not to kinda rip on it-

    18. TFTim Ferriss1:33:41

        Not to get too technical [laughs]

    19. PADr. Peter Attia1:33:42

        ... but it's like, you know... Yeah, yeah. But it's like, you know, that's sort of the problem with doing a lot of sort of fun classes and stuff. Look, it's absolutely better than sitting on the couch, for sure.

    20. TFTim Ferriss1:33:52

        Mm-hmm.

    21. PADr. Peter Attia1:33:53

        But it's not specific enough to achieve this goal. So you really wanna kinda separate that zone two from that zone five. And when it comes to VO2 max, you basically have to be in the three to eight-minute range is the sweet spot. So it's gotta be intervals that are about three to eight minutes, so three minutes at the low end-

    22. TFTim Ferriss1:34:13

        Mm-hmm

    23. PADr. Peter Attia1:34:13

        ... meaning you're doing something that is so hard you can only do it for about three minutes, and at the high end, eight minutes. So if you can do it for more than eight minutes, it's not doing a lot for your VO2 max. If you can't do it for three minutes, it's also not doing the maximum amount for your VO2 max.

    24. TFTim Ferriss1:34:26

        And just for clarity, that's the zone five that you're referring to, building the peak?

    25. PADr. Peter Attia1:34:30

        Yeah, exactly. And here you're typically doing about a one-to-one work to rest recovery. That's how hard these intervals are. If you do three minutes at whatever that output is, you're gonna need about three minutes of recovery before you can do it again.

    26. TFTim Ferriss1:34:46

        Mm-hmm.

    27. PADr. Peter Attia1:34:47

        So we typically say, look, a good starting point is four by four. Four on, four off, four times.

    28. TFTim Ferriss1:34:55

        Mm.

    29. PADr. Peter Attia1:34:55

        That's just a great workout to start. Just doing that workout once a week. So if, let's say, three days a week you're gonna do your cardio and it's gonna be kind of the low end, zone two cardio, one day a week you s- you pick an exertion level that you can barely get through four minutes of it. You can do it, but, you know, you have a little bit left in the tank, but not much, and that, that you need four minutes to recover, and then you do that four times sandwiched between a warmup and

17. 1:35:22 – 1:38:14

    Finding the zone two sweet spot.

    1. PADr. Peter Attia1:35:22

       a cool-down.

    2. TFTim Ferriss1:35:23

       If I'm understanding correctly, that would be the building of the peak. What does the zone two training look like for you or your clients?

    3. PADr. Peter Attia1:35:30

       Long and slow.

    4. TFTim Ferriss1:35:31

       I guess what I'm wondering is, aside from subjective perceived exertion-

    5. PADr. Peter Attia1:35:36

       Mm-hmm

    6. TFTim Ferriss1:35:36

       ... is there a heart rate range or anything else that you can use as sort of a proxy indicator so people can have something to aim for?

    7. PADr. Peter Attia1:35:48

       Yeah. Once you get fit enough, lactate becomes really good. So measuring lactate with a point of care, like a finger prick device, is what I do.

    8. TFTim Ferriss1:35:57

       Yeah.

    9. PADr. Peter Attia1:35:57

       And you're, you're looking for a lactate level of about 1.7 to two millimole for most people is the zone. For people who aren't yet fit enough, their lactates are usually gonna be way higher than that while they're still training that energy system, or if people just don't wanna do that. And for those people, RPE, rate of perceived exertion, is really the best way to do it, and it's far more accurate-

    10. TFTim Ferriss1:36:21

        Mm

    11. PADr. Peter Attia1:36:21

        ... than heart rate.

    12. TFTim Ferriss1:36:22

        Mm.

    13. PADr. Peter Attia1:36:23

        So the RPE is you should be able to talk, but you don't want to.

    14. TFTim Ferriss1:36:28

        Mm.

    15. PADr. Peter Attia1:36:28

        So today I did a zone two ride. I spent the enti- This is very unusual, but just because of the way it was today, I spent the entire zone two on a phone call.

    16. TFTim Ferriss1:36:39

        Mm.

    17. PADr. Peter Attia1:36:39

        My entire workout was on a phone call. There was absolutely no confusion on the part of the guy on the other end of that line that I was on my bike, and that I wanted him to talk more than me. [laughs]

    18. TFTim Ferriss1:36:50

        Mm-hmm.

    19. PADr. Peter Attia1:36:50

        Like, I was breathing like this. It was like, [inhales] "Okay," so, [inhales] "Yeah." You know? Like, I mean, that's, that's kind of how I was going at it.

    20. TFTim Ferriss1:37:00

        Mm-hmm.

    21. PADr. Peter Attia1:37:01

        I can nasally breathe when I'm doing zone two, but it's... I'm right at the limits of what I can do, and it's very easy for me to nasally breathe. Like, I don't mouth breathe at night or anything like that. So that kinda gives you a sense of it.

    22. TFTim Ferriss1:37:11

        Mm-hmm.

    23. PADr. Peter Attia1:37:11

        If you can talk pretty easily while you're doing it, like if you're out on a walk and you're talking to somebody, that's too easy. If you can't talk at all, that's too hard.

    24. TFTim Ferriss1:37:20

        Mm-hmm.

    25. PADr. Peter Attia1:37:22

        And I think that is by far the best test.

    26. TFTim Ferriss1:37:25

        And just to, to give people some more specifics, so for the zone two, how long would a target session be? How many times per week? And then similarly for the four by four, let's just say, that you described for the zone five, building the peak, how many times per week would you do that?

    27. PADr. Peter Attia1:37:41

        I think if we can do that once a week is great.

    28. TFTim Ferriss1:37:44

        That's zone five?

    29. PADr. Peter Attia1:37:46

        Yeah, zone five. And I think for zone two, we think minimum effective dose. So again, it depends on where you're starting. If you're starting with you've never exercised in your life, I mean, boy, we'd be happy to get you doing two 30-minute-a-week zone two sessions. But you very quickly will start to adapt to that, and I, and then I think we start to get into three hours being the MED.

    30. TFTim Ferriss1:38:07

        Oh, wow. Okay.
18. 1:38:14 – 1:40:01

    How skinning and rucking have upped my endurance.

    1. TFTim Ferriss1:38:14

       Mm-hmm. Have you ever tried, Peter, and I'm just gonna bring this up because we've spent a good amount of time together, and this has been a, a bit of a revelation for me. Have you ever tried skinning on skis? Going uphill with skins on skis?

    2. PADr. Peter Attia1:38:29

       I have not, but Lance Armstrong's a good buddy, and, you know, he moved out of Austin to Aspen a few years ago.

    3. TFTim Ferriss1:38:36

       Mm-hmm.

    4. PADr. Peter Attia1:38:36

       And I, I keep giving him crap for it, and I'm like, "Dude, why did you leave? Why did you leave?" And he's like, "Yeah, it's tough." I mean, especially in the winter, because he's a summer sport guy, but this is his form of winter exercise.

    5. TFTim Ferriss1:38:47

       Mm.

    6. PADr. Peter Attia1:38:47

       And having him describe it to me, I'm like, yeah, I can see that. That sounds pretty awesome, actually.

    7. TFTim Ferriss1:38:52

       So you know this, Peter, but people listening may not. I historically am about as far from an endurance athlete as you could possibly be in the sense that if you look at my sports career, such as it was, it's all optimizing for trying to win very quickly, within three to five minutes generally. And anything close to extended exercise has always been rightly, and probably wrongly, punishment in my view. I just have really disliked it, which means I've gravitated towards weight training, things like that. Skinning and rucking are the two things that have changed that. My body, including, like, my low back pain and so on, feels so much better when I am doing-

    8. PADr. Peter Attia1:39:40

       Mm

    9. TFTim Ferriss1:39:40

       ... skinning and rucking. I will say with the rucking, and I don't know what your setup looks like, but I really benefit from having a waist strap. There are rucking backpacks out there that do not have a waist strap, and I find those can cause some back pain if, if I have either too much weight, use them for too long, or, or both.

19. 1:40:01 – 1:44:00

    Rucking vs. weighted vests.

    1. PADr. Peter Attia1:40:01

       Can I make a shameless plug for my friend Jason McCarthy's company, GORUCK?

    2. TFTim Ferriss1:40:06

       Yeah, please.

    3. PADr. Peter Attia1:40:07

       I have no affiliation, but I, I love Jason and I love the company. So yeah, the GORUCK is the way to go here.

    4. TFTim Ferriss1:40:13

       Mm-hmm.

    5. PADr. Peter Attia1:40:14

       You just need a backpack with weight, but if you want to invest in it, they make amazing packs. You can buy these bolt-on waistbands that allow you to support. 'Cause I'm like you. I like to have 80% of the weight on my hips-

    6. TFTim Ferriss1:40:27

       Yeah

    7. PADr. Peter Attia1:40:27

       ... and virtually none of it on my shoulders. I don't even link up the little strap across my chest, 'cause I wanna be able to breathe fully.

    8. TFTim Ferriss1:40:34

       Mm-hmm.

    9. PADr. Peter Attia1:40:34

       So I'm very light on the shoulders, incredibly heavy on the hips, and-

    10. TFTim Ferriss1:40:40

        Mm-hmm

    11. PADr. Peter Attia1:40:40

        ... you know, their packs and the weights that come with them just make this a very elegant solution. So yeah, totally agree.

    12. TFTim Ferriss1:40:46

        I also use GORUCK, so I'll give them a plug. I don't know the founders, but ended up honing in on, on GORUCK. And I will say also the breathing component, aside from the loading distribution that you just mentioned, one of the benefits that I find of rucking versus, say, a weighted vest, which are quite popular in the CrossFit community-

    13. PADr. Peter Attia1:41:07

        Absolutely

    14. TFTim Ferriss1:41:08

        ... and so on, is the, the where you are bearing the weight and also the ability to breathe. So those would be-

    15. PADr. Peter Attia1:41:13

        Mm-hmm

    16. TFTim Ferriss1:41:13

        ... two advantages. And I'm sure there's a lot to be said for the, the weighted vests as well. Although, funny, I'll tell you, Peter, I don't know if I ever told you this. This was probably 2009, 2010, I decided I was gonna try weighted vests, and I was like, "This is gonna be fantastic. I can't wait." [laughs] And so I bought this monster, which was loaded up. It looked like a suicide bomber vest. It just had, like, all these k- they looked like canisters full of weight.

    17. PADr. Peter Attia1:41:38

        How much did it weigh?

    18. TFTim Ferriss1:41:40

        Well, okay, I'll get there. So I thought to myself, it's just walking. At that point, I was very seriously, and I know this is not winning any records, but for me it was a lot. I mean, I was probably 180, and I was dead lifting 475 for reps, which is as high as I got. And I thought to myself, I walk all the time. Let me get, I think it was a 100-pound vest. So I get this 100-pound vest and I put it on, and I decide to go for a leisurely, you know, two or three-mile walk, and I get a mile out and I'm like, "I can't carry this thing. I'm gonna f- [laughs] I'm just gonna collapse into a puddle on the sidewalk." So I had to leave the vest on the sidewalk, this is in, like, the Mission in San Francisco, and go back to my house to get a car to come get it. And I thought to myself, if anybody steals this thing, they deserve to have it. And not surprisingly, the weight vest did not move. It stayed exactly where it was. So yeah, rucking. I suggest r- rucking, and start lighter than you think. [laughs]

    19. PADr. Peter Attia1:42:39

        It... Yeah, I recommend people start with a sixth to a quarter of their body weight.

    20. TFTim Ferriss1:42:44

        Yeah. Or it's a good chance you'll end up dropping it somewhere. [laughs]

    21. PADr. Peter Attia1:42:47

        Yeah, and, and truthfully, I think, you know, Michael Easter, who's written about this extensively in, in his book, The Comfort Crisis, which if your listeners haven't read that-

    22. TFTim Ferriss1:42:55

        Yeah

    23. PADr. Peter Attia1:42:55

        ... not that we're trying to give them more books to read. But The Comfort Crisis-

    24. TFTim Ferriss1:42:58

        Mm

    25. PADr. Peter Attia1:42:58

        ... I can't recommend highly enough. You know, I think he said that even the military right now thinks that you don't really need to go above a third of your body weight.

    26. TFTim Ferriss1:43:06

        Mm-hmm.

    27. PADr. Peter Attia1:43:07

        So let gravity help you more than that. But, you know, sort of anywhere from a sixth to a third of your body weight is probably the sweet spot.

    28. TFTim Ferriss1:43:14

        Yeah. Where I've ended up, and this will make me sound weak maybe, but is right around 45. In some cases I've added a bit more weight. But I, I probably weigh 175 right now. 45 and then focusing on inclines. Basically just going for the sort of-

    29. PADr. Peter Attia1:43:29

        Mm

    30. TFTim Ferriss1:43:29

        ... geographical altitude, or not even necessarily altitude, but the incline challenge rather than slapping on a ton of weight and walking on flatter ground.
20. 1:44:00 – 1:49:26

    Are neurodegenerative diseases preventable?

    1. TFTim Ferriss1:44:00

       and maybe this is a place to talk about what you have learned about a neurodegenerative disease and specifically perhaps Alzheimer's, because I think this will all tie in and show people that the sort of Cartesian duality of body and mind is really illusory. Could you speak to that?

    2. PADr. Peter Attia1:44:23

       Probably the first time I took a hard look at this would've been 2014, maybe 2015. And at the time I, I had one analyst, his name was Dan Pelchar, look at this in detail. And, and God, it was a, uh, it was probably a six to nine-month project. I mean, it was a really, really exhaustive look at the literature and, you know, the deepest dive we could do at the time of what do we know about the prevention of Alzheimer's disease? So again, we started with a very bold hypothesis, which we were not alone in, but most people thought was crazy, which was that these diseases have some degree of prevention.

    3. TFTim Ferriss1:45:11

       Mm-hmm.

    4. PADr. Peter Attia1:45:11

       There is a way to prevent these to some extent. Maybe not completely, but luck is not the only thing, or bad luck is not the only thing that is driving these diseases. We have some control. And so to make a very long story short, after Dan kind of went through all of this analysis and after analysis after analysis, the thing that stood out above everything else was the benefit of exercise. And I just sort of told Dan to go back to the drawing board. I was kind of like, "Dan, I think you screwed this analysis up, buddy."

    5. TFTim Ferriss1:45:44

       [laughs]

    6. PADr. Peter Attia1:45:45

       Like, there's zero chance that exercise is actually the best thing here. Like, are, are you gonna now tell me that chicken soup is the best thing for colds? Like-

    7. TFTim Ferriss1:45:55

       [laughs]

    8. PADr. Peter Attia1:45:56

       ... I wanted some insight here. I didn't want some stupid platitude, right? But it turned out Dan was right and I was wrong. So I, I think, I think the data are pretty unambiguous. You know, in fact, I'm doing a podcast on this, I don't know, by the time this one's out, it might be out. I don't, I don't know. I don't know. But, but I've got a podcast coming out on sort of, you know, brain health, and here we are back again now with, you know, many more analysts and much more tools at our disposal to kind of understand the literature, and still exercise remains the most important modifiable behavior we have to reduce the risk of Alzheimer's disease, and probably Parkinson's and Lewy body dementia, by the way.

    9. TFTim Ferriss1:46:37

       Mm.

    10. PADr. Peter Attia1:46:37

        So I can't say that for every single neurodegenerative disease, right? I can't... I don't have any real insight into how you prevent Lou Gehrig's disease, which is an absolutely horrific disease that is fortunately much more rare. But when it comes to the big three, Alzheimer's, Parkinson's, and Lewy body dementia, exercise, exercise, and exercise matter. And part of that has to do with movement reserve.

    11. TFTim Ferriss1:47:01

        Mm-hmm.

    12. PADr. Peter Attia1:47:01

        So, you know, when you think about Lewy body and Parkinson's, these are primarily movement disorders, right? So they're kind of on a spectrum, right? So you've got Parkinson's at one end, pure movement disorder, little bit of cognitive. Lewy body, kind of a bit of both, and then Alzheimer's much more cognitive. Having a higher movement reserve and having a higher cognitive reserve are protective.

    13. TFTim Ferriss1:47:20

        What do you mean by movement reserve? Just greater range of motion, ability, sort of spectrum of movement patterns that they-

    14. PADr. Peter Attia1:47:26

        Yes

    15. TFTim Ferriss1:47:26

        ... can sustain?

    16. PADr. Peter Attia1:47:27

        Greater physical capacity, right? So, you know, people who are really good dancers, who are really good at doing complicated, coordinated problem-solving things with their body, who have kinesthetic awareness, they're going to have a much slower decline even when diagnosed with Parkinson's disease, for example.

    17. TFTim Ferriss1:47:48

        Hmm.

    18. PADr. Peter Attia1:47:48

        So we want our cognitive reserve high, we want our movement reserve high, and then on the other side of that, you get the sort of kind of hormonal, vascular, metabolic benefits that come from the actual exercise. So one is the benefits you get from being in the state. One is the benefits you get accruing the state.

    19. TFTim Ferriss1:48:08

        Hmm. Could you expand a bit on the hormonal effects and otherwise? I mean, I think this is probably just because it has [chuckles] words in the acronym that I like, but brain-derived neurotrophic factor, et cetera. I mean, to what extent can you weight some of these factors?

    20. PADr. Peter Attia1:48:23

        Yeah, I don't know that I could tell you a relative weighting, but certainly BDNF is a very important one. So it's a very important, you know, growth factor for neurons. But also, of course, when you think about the metabolic effects and the hormonal effects that come from what is exercise doing to cortisol levels? What is exercise doing with glucose and insulin levels? I mean, we, we see an unbelievably strong association between type 2 diabetes and Alzheimer's disease.

    21. TFTim Ferriss1:48:50

        Mm-hmm.

    22. PADr. Peter Attia1:48:51

        Well, again, here's an example of where Medicine 3.0 I think gives you a little bit more confidence to make the extension, which is, look, if type 2 diabetes is bad, having insulin resistance without type 2 diabetes is also probably bad.

    23. TFTim Ferriss1:49:03

        Mm-hmm.

    24. PADr. Peter Attia1:49:04

        And therefore, we want to take all steps possible to maximize insulin sensitivity, glucose disposal, all of these things that fit under the bucket of metabolic health. And again, exercise is not unique in its ability to act on those things. Nutrition absolutely does as well. But boy, does exercise have a profound effect on those things.

21. 1:49:26 – 1:51:40

    Helping your doctor understand and embrace Medicine 3.0.

    1. TFTim Ferriss1:49:26

       Yeah. Let's talk about training the trainer maybe. By that, I mean the vast majority of people listening to this will not be able to work with you or a practice like yours. What types of requests can they make of their physicians? What types of tests might they ask for? And this may be a, a clumsily worded question, but how can they make their doctor and their- ... health plan per se better? Are there any recommendations you have?

    2. PADr. Peter Attia1:50:06

       Yeah. Look, I think that it kind of comes back a little bit to your medical literacy question at the outset, right? Which is, I think part of it is also just being a bit more clear about what your objectives are when you're finding a doctor and understanding a little bit about what their style is. I mean, asking them what's, what is their philosophy on something? How much time do you spend learning about things that you did not learn in medical school? I go back to something I said earlier, which was, there's almost nothing I do today, Tim, that I learned in medical school.

    3. TFTim Ferriss1:50:39

       Mm.

    4. PADr. Peter Attia1:50:39

       I can't think of one thing, and it's not because what I learned in medical school wasn't valuable, it's just that... And maybe that's the wrong example, by the way. Let, let's be a little more-- let's be a little less glib. If I look at the physicians in my practice who trained in internal medicine and ask the question, "What did you learn in residency that you're using today?" The answer's probably like 10 to 15 to t- maybe 20% max. So where did that other 80% come from? And I'm arguing that if you wanna participate in Medicine 3.0, you have to be able to learn outside of your training.

    5. TFTim Ferriss1:51:17

       Mm.

    6. PADr. Peter Attia1:51:17

       And I think that's, that's a discussion that should be had very deliberately and not obliquely.

    7. TFTim Ferriss1:51:23

       Mm-hmm.

    8. PADr. Peter Attia1:51:25

       So I think understanding where they sit on prevention, understand-

    9. TFTim Ferriss1:51:28

       Mm

    10. PADr. Peter Attia1:51:28

        ... how they're educating themselves, what are they reading, what are they learning?

    11. TFTim Ferriss1:51:32

        Mm-hmm.

    12. PADr. Peter Attia1:51:34

        And, and if the answer is, "Hey, it's not a good fit," great. Better to find that out before you jump in.

    13. TFTim Ferriss1:51:39

        Yeah. And

22. 1:51:40 – 1:56:37

    How much is an ounce of prevention worth to you?

    1. TFTim Ferriss1:51:40

       as we're talking about this, two things came to mind, and please feel free to dismantle this. But the first is, to be able to assess medical literacy, you have to have a certain base level of medical literacy yourself. So I would say kinda step number one is developing a working vocabulary and also frameworks, many of which you, you provide in Outlive, such that you can actually assess other people to some extent, right? That's kinda step one. The second is that if we think about many Western-trained, or I shouldn't say Western-trained, physicians who are sort of schooled in a, in a Western paradigm as those focused on the sort of addressing of disease rather than prevention of disease, broadly speaking, and that may be, may be unfair to paint so broadly, but let's stick with that for a minute. That as you think of your healthcare, it goes beyond just your primary care physician and could very well, and probably should, include people like exercise physiologists or people who are trainers, given, given how much overlap and integration we've discussed in the course of our conversation. And it just occurred to me that, and this I think is, is quite true, that it's a lot easier... Not that you shouldn't look for concierge doctors. If you have the means and that's a possibility, by all means, do that. But you can find excellent, excellent strength coaches, I, I would say much more easily than you may be able to get yourself into a economic position where you can afford concierge medicine. And the payoffs, I'm not saying they're comparable, but the payoffs of having a good strength coach or an endurance coach go a long way. So those came to mind also. So let's just say they're asking these questions of their doctors. They find a doctor. Are there any particular recommendations you would have? A couple of things come to mind that I have in my notes here related to tests to request. For instance, I don't know where you stand now on Grail, which I guess would be considered sort of a liquid biopsy, right?

    2. PADr. Peter Attia1:54:01

       Mm-hmm. Yep.

    3. TFTim Ferriss1:54:02

       Scans like PreNuvo, for instance, and perhaps more intelligent approach to family history is something that I know you cover in the book. Would you like to speak to anything that might fall in that category of things to consider requesting?

    4. PADr. Peter Attia1:54:20

       Yeah. We think it's really important to be testing, you know, as I said, ApoE is one thing for sure. We really do want to know that genotype. And again, if you believe that Alzheimer's disease has some element of prevention baked into it, then knowing that you're high risk should be a valuable thing to understand. When it comes to understanding cardiovascular disease, you know, we care deeply about ApoB. ApoB, again, being a more important metric than LDL cholesterol or non-HDL cholesterol or HDL cholesterol. This ApoB is the concentration of all atherogenic particles, so includes all the HDLs, VLDLs, et cetera. Also, knowing Lp little a, which is a genetically determined very high-risk particle that, while it can't be modified, will allow you to understand how much more you need to optimize, for example, ApoB. So knowing Lp little a, knowing ApoB, knowing ApoE. There are other biomarkers, obviously, that we care deeply about. You know, uric acid, homocysteine, insulin, liver function tests. Cystatin C is one that I think is largely underappreciated. So-

    5. TFTim Ferriss1:55:30

       Hmm

    6. PADr. Peter Attia1:55:30

       ... it's-- most doctors are using creatinine as the measure of kidney function. Creatinine is a joke, actually. At some point, I wish I had the time, and maybe I'll make the time to do a deep dive into how it became the de facto gold standard for measuring and estimating-

    7. TFTim Ferriss1:55:44

       Hmm

    8. PADr. Peter Attia1:55:44

       ... glomerular filtration rate. It's an absolute atrocity. So for a person who's very low in muscle mass, it really overestimates kidney function. For a person with high muscle mass or who's just exercised, it really underestimates kidney function, but it virtually never correctly estimates kidney function. Whereas-

    9. TFTim Ferriss1:56:03

       Hmm

    10. PADr. Peter Attia1:56:03

        ... cystatin C, which is another blood test, probably costs a few more dollars, but certainly not much. You know, it might be the difference of $1 versus $7 or something. completely more accurate and unlinked to these issues of muscle mass and exercise.

    11. TFTim Ferriss1:56:19

        How do you spell cystatin C?

    12. PADr. Peter Attia1:56:21

        C-Y-S-T-A, cystat. Like it's, it says it sounds phonetically. I never, I couldn't do the spelling bee.

    13. TFTim Ferriss1:56:27

        [laughs] Okay.

    14. PADr. Peter Attia1:56:28

        But it's C-Y, C-Y. [laughs]

    15. TFTim Ferriss1:56:31

        People will find it on Google.

    16. PADr. Peter Attia1:56:33

        Yeah, exactly. Don't ask, don't, don't ask me to spell anything longer than A.

23. 1:56:37 – 2:05:02

    Early cancer screening.

    1. TFTim Ferriss1:56:37

       All right. How about on the early cancer screening side?

    2. PADr. Peter Attia1:56:41

       Well, again, that cancer chapter is probably a very long chapter for a reason.

    3. TFTim Ferriss1:56:44

       Yeah.

    4. PADr. Peter Attia1:56:45

       But I think one of the big takeaways on that chapter is the overwhelming evidence that treating cancers when they are detected early has significantly better outcomes than treating the exact same cancer later on down the line, even using the same cocktail of drugs. I think the two examples in the book I use are that of colon cancer and breast cancer, and looking at, you know, for example, using the FOLFOX regimen of chemotherapy to treat a patient with adjuvant treatment. Meaning, so a person that had a stage two or stage three colon cancer that is resected, and at least surgically, you don't see any gross disease. They just have microscopic disease. You treat those people with the FOLFOX chemo regimen, which is a multi-drug regimen, and you compare that to people who have metastatic disease, the outcomes are vastly different, right? In the latter group, nobody's gonna survive for 10 years, and very few of them will make it five years. In the former group, you know, 80-plus percent are gonna survive 10 years. Go through the similar example with breast cancer. The point here is the fewer tumor cells you have, the smaller the burden of cancer, the fewer the mutations, the fewer the escape mechanisms that are in place to evade the immune system, the more likely you are to survive treatment. And therefore, until we figure out ways to completely eliminate cancer, which I don't think are going to happen anytime soon, we have to take a much more aggressive posture towards screening and acknowledge, by the way, the downside of that. So there's a significant downside to more aggressive screening. But if you can, if you can come to grips with that, you have a better chance of beating cancer by far. And to your question now, GRAIL becomes one of the tools we would think about doing that. So GRAIL is a company, I guess it's currently or now probably owned by Illumina, and it's, it uses something called cell-free DNA. So it takes a blood, a couple tubes of blood, and looks in there for tiny, tiny, tiny amounts of DNA that are out of the cell. So most of the DNA, if, you know, Tim, if you went and did a DNA test and they took blood, they would take the DNA out of cells in your blood. They'd break down red blood cells and white blood cells and take the DNA. But this technique looks at all the DNA which is not in cells, which is, you know, a fraction of a fraction of a fraction of a percent. They look at that DNA, and by looking at the methylation pattern of it, so these little methyl groups that are stuck to it, they impute two things. One, is cancer likely to be present, yes or no? And if yes, can we figure out what organ it is?

    5. TFTim Ferriss1:59:33

       Mm.

    6. PADr. Peter Attia1:59:34

       You know, where did it come from? These tests have a relatively low sensitivity, meaning if a cancer is present, their, their ability to detect it is not that high. They have a very high specificity, which means if no cancer is present, they are very likely to tell you that. Every screening test has to be tuned towards sensitivity versus specificity, and this test is tuned to very high specificity, very low sensitivity. Knowing the sensitivity and specificity of a diagnostic test is only slightly useful. If you don't know the prevalence of the condition you're testing for, which is called the pretest probability, you can't actually impute what's called positive and negative predictive value. In other words, what you really want to know when you look at a diagnostic test before you take it is, if it's positive, how likely is it that I have the condition? If it's negative, how likely is it that I don't have the condition? That's positive and negative predictive value respectively. And you can only answer that question when you know not only the sensitivity and specificity, but what your pretest probability is.

    7. TFTim Ferriss2:00:44

       Mm-hmm.

    8. PADr. Peter Attia2:00:45

       And if you don't know that, you would just say, "Well, what's the prevalence of the condition in where I'm looking?" So when you take cancer screening in a general population, the prevalence is very low. Right? It'd be one percent, two percent. You know, a hundred people that walk into for a random cancer screening, you wouldn't expect more than one or two of them have cancer. So with a low sensitivity and a high specificity test, you have, if you do the math, you'll see very low positive predictive value and very high negative predictive value. And for that reason, I, I think initially was not blown away by the test because of how low the sensitivity was. For low stage cancers, like stage one and stage two, the sensitivity was like twenty percent. And that's, that's the metric that I cared most about. I don't really care about your sensitivity at detecting stage four cancer. We've, we've blown it if we're waiting until that point. What is very interesting to me, though, is when you start to look at this by histology, and this to me is interesting. If you look at all breast cancer, the stage one, stage two sensitivity for detection is twenty-ish percent. But if you look at hormone negative breast cancer, it's seventy-five percent. If you look at hormone positive cancer, it's, you know, twenty percent basically.

    9. TFTim Ferriss2:02:08

       What do you mean by hormone negative and positive?

    10. PADr. Peter Attia2:02:11

        So one of the most important ways that we identify breast cancer is by its hormone profile. So is it estrogen ... progesterone and or HER2/neu positive. So triple negative breast cancer has the worst prognosis. So a breast cancer that, uh, has, does not express the progesterone, estrogen, or HER2/neu receptors has the worst outcome. It's the most aggressive breast cancer.

    11. TFTim Ferriss2:02:34

        Mm-hmm.

    12. PADr. Peter Attia2:02:34

        And those cancers, even at the same stage, are far more detectable. They have a 75% sensitivity-

    13. TFTim Ferriss2:02:42

        Mm

    14. PADr. Peter Attia2:02:42

        ... in low stage cancer.

    15. TFTim Ferriss2:02:44

        Hm.

    16. PADr. Peter Attia2:02:45

        This tells us that we need to think of liquid biopsies in a very different way from how we think about, quote unquote, "anatomic screening." So a mammogram or an MRI or an ultrasound are agnostic to the properties of the cancer. They are simply looking at its presence and size. What this liquid biopsy might be giving us a, a window into is the behavior of a cancer. Why is it that a triple negative, I'm using the terminology looser, but let's just say I got a 75% chance of catching it in the bloodstream even at an early stage, whereas if it's triple positive, which has a much better outcome, I'm not gonna catch it very likely at that stage. Might it be that because the latter is not that lethal, and therefore it's not shedding, and the former-

    17. TFTim Ferriss2:03:34

        Mm

    18. PADr. Peter Attia2:03:34

        ... is much more lethal, and that's why the cancer is spreading? So I think it's super early days on this, and I think these, you know, cancer screening is definitely one of the most contentious things that, you know, I probably talk about in the book because I do take, uh, I think, a, a very different view from the mainstream, which is that, you know, we have to do this aggressively. We have to do this early. I mean, I'm, I'm just 50 years old. I've already had... You know, I, I'm, I'm three colonoscopies in at 50, right?

    19. TFTim Ferriss2:04:05

        Mm.

    20. PADr. Peter Attia2:04:05

        So, you know, I, I just... To me, it's, just as it's unacceptable, I think, to die of cardiovascular disease in the year 2023, I think it's unacceptable to die of colon cancer, and yet colon cancer is the third leading cause of cancer death.

    21. TFTim Ferriss2:04:19

        Yeah. Yeah, I will just say, I'm not gonna name names, but a friend of mine put off colonoscopy for a few years, older guy, and-

    22. PADr. Peter Attia2:04:28

        Yeah, I know who you're talking about.

    23. TFTim Ferriss2:04:30

        Yeah, stage four. So early counts, early counts a lot. And I'm just gonna leave a couple of gingerbread trails for folks because I do want them to pick up the book. I mean, there's so much. We couldn't even scratch the surface in, in our conversation. But the contrasts between, say, CT angiogram over calcium score or calcium scan, I mean, there's so much we could dig into. Immunotherapy and, and many other things. But what I'd like to do, you'll probably get a kick out of this,

24. 2:05:02 – 2:07:20

    Outlive chapters.

    1. TFTim Ferriss2:05:02

       number one, I think you have some of the best chapter names I've seen in a long time, so I wanna, I wanna give you credit where credit is due, and then where I think I'd like to go is to ask you about-

    2. PADr. Peter Attia2:05:13

       By the way, some of those, Bill Gifford might deserve some of the credit, my co-author.

    3. TFTim Ferriss2:05:16

       Mm.

    4. PADr. Peter Attia2:05:17

       I was really struggling for some chapters with quotes. You know, we, as you probably noticed, each chapter has a quote.

    5. TFTim Ferriss2:05:23

       Mm-hmm.

    6. PADr. Peter Attia2:05:23

       And I think Bill probably came up with three-quarters of them.

    7. TFTim Ferriss2:05:27

       Oh, nice.

    8. PADr. Peter Attia2:05:27

       I was really struggling with the quotes 'cause I-

    9. TFTim Ferriss2:05:30

       [laughs]

    10. PADr. Peter Attia2:05:30

        ... I had some that were okay, but he would always come through in the end with a better one, so...

    11. TFTim Ferriss2:05:34

        [laughs] Well, credit to Bill. But what I'd like to do, just to give people a lay of the land, is actually, this is gonna sound ridiculous, but just read through these briefly, and then what I'd like to talk about is how and why you decided to include the chapter The High Price of Ignoring Emotional Health. So if you'll bear with me here, I'll just do a little [clears throat] recital.

    12. PADr. Peter Attia2:05:57

        Mm.

    13. TFTim Ferriss2:05:57

        So, [laughs] so chapter one, The Long Game: From Fast Death to Slow Death. And I'm not gonna give the chapter numbers, I'm just gonna go through these. Medicine 3.0: Rethinking Medicine for the Age of Chronic Disease. We touched on this briefly. Objective, Strategy, Tactics: A Roadmap for Reading this Book. Centenarians, this is coming into part two, The Older You Get, the Healthier You've Been. Eat Less, Live Longer, question mark, The Science of Hunger and Health. One Disease to Rule Them All: The Crisis of Abundance. The Ticker: Confronting and Preventing Heart Disease, the Deadliest Killer on the Planet. That's my chapter, as you know. If anything's gonna kill me that isn't an accident, it is probably heart disease. The Runaway Cell: New Ways to Address the Killer that is Cancer. Chasing Memory: Understanding Alzheimer's Disease, also something in my family, and Other Neurodegenerative Diseases. Part three, we're rounding the bend here, coming into home. Thinking Tactically: Building a Framework of Principles that Work for You. Exercise: Nature's Longevity Drug. Training 101: Training for the Centenarian Decathlon, which for those long-term, long-term podcast listeners, that may sound familiar, and it's certainly been refined and developed in the form that you find in this book. The Gospel of Stability: Relearning How to Move to Prevent Injury. Nutrition 3.0: You Say Potato, I Say Nutritional Biochemistry. [laughs] That's the most Peter thing I've ever read. Putting Nutritional Biochemistry into Practice. New Rules for Changing the Way You Eat. The Awakening: Tap into

25. 2:07:20 – 2:09:01

    The chapter on emotional health that almost didn’t make the book.

    1. TFTim Ferriss2:07:20

       the Power of Sleep. And then, last but not least, Work in Progress: The High Price of Ignoring Emotional Health. Why the last chapter?

    2. PADr. Peter Attia2:07:29

       Well, I'll tell you something funny. When I had an early draft of the book, I shared it with a mutual friend of ours, Hugh Jackman, and H- Hugh read it, and his only feedback was, "That should be the first chapter."

    3. TFTim Ferriss2:07:44

       Hm.

    4. PADr. Peter Attia2:07:46

       Hugh had a, a really solid argument for why that was the case. The publisher absolutely said, "No chance in hell."

    5. TFTim Ferriss2:07:52

       [laughs]

    6. PADr. Peter Attia2:07:53

       And so it was either nowhere or at the very end of the book. [laughs] This was the hardest chapter to write, unquestionably. It's the 17th chapter that has very little to do with the other 16, for reasons I won't necessarily explain here, but it's, it's a very different format, it's a very different structure, and it tells a very different story. But-

    7. TFTim Ferriss2:08:16

       Hm

    8. PADr. Peter Attia2:08:16

       ... look, I think for some people it might be the most important chapter in the book, and I think for others it might be totally irrelevant. But that was a risk, I think, that was worth taking And I'll just say this. Uh, I think you alluded to this earlier on several occasions. Longevity without healthspan is the greatest curse in the world, right? Like, to live a long life and to suffer is not to live. And that suffering, that loss of healthspan can be cognitive, it can be physical, and it can be emotional. And that last one is so squishy that it's hard to talk about in a medical book. But that chapter is basically my way of trying to do that.

    9. TFTim Ferriss2:08:59

       Hmm.

26. 2:09:01 – 2:13:24

    Peter’s 47 affirmations.

    1. TFTim Ferriss2:09:01

       So I just wanna give some... If you don't mind, I'll give a teaser. Now, there's, there's a lot to this chapter. We're not gonna dig into all of it, but maybe we could start with, and we won't spend too, too much time, as I'm watching the lighting and the sun [laughs] and the moon and the stars changing your video, because I know we've been going for a while. But are you open to discussing the 47 affirmations that you had to write and the context, a little bit of the context around that? 'Cause I th- I think a lot of people listening to this will identify with certainly that particular instance of your experience.

    2. PADr. Peter Attia2:09:48

       Yeah. Boy, it's hard to explain that without explaining where I was when I was being asked to do that, but-

    3. TFTim Ferriss2:09:53

       Sure. You can say whatever you'd like to

    4. PADr. Peter Attia2:09:54

       ... so let's just say I was in a rehabilitation center where one of my homework assignments on the first day was to write an affirmation for each year I'd been alive. At the time, I was 47. This was three years ago. So it was, you gotta come up with 47 things to say about yourself that are positive. And I couldn't come up with more than a few. I was sort of stuck at four or five until the 19th day, and then I really kind of had an enormous breakthrough that honestly in the book is... I, I don't devote a lot of real estate to it, as profound as it is, but, but I think a person reading this who's been where I'm taking you will understand it. But I think once I reached that point, once I had that breakthrough, as I describe in the book, I was able to write the remaining 43 of them in 20 minutes.

    5. TFTim Ferriss2:10:57

       Hmm.

    6. PADr. Peter Attia2:10:58

       Those 47 affirmations then became a very big part of my kind of recovery contract, and for a period of about six months, I would read those twice a day every day standing in front of a mirror, which sounds very sort of Stuart Smalley, or whatever that character's name was.

    7. TFTim Ferriss2:11:13

       [laughs]

    8. PADr. Peter Attia2:11:13

       What was his name?

    9. TFTim Ferriss2:11:13

       Yeah, yeah. Yeah.

    10. PADr. Peter Attia2:11:14

        Smiley? Smiley? Smalley? I don't know.

    11. TFTim Ferriss2:11:16

        Something like that. I can't remember. Right.

    12. PADr. Peter Attia2:11:17

        Yeah.

    13. TFTim Ferriss2:11:18

        "I'm good enough-

    14. PADr. Peter Attia2:11:18

        I'm good enough-

    15. TFTim Ferriss2:11:18

        "... people can dash on it, and people like me."

    16. PADr. Peter Attia2:11:20

        ... and people, and people. That's right. That's right.

    17. TFTim Ferriss2:11:22

        [laughs]

    18. PADr. Peter Attia2:11:22

        But I think for, for my problems, this was a, such an important step.

    19. TFTim Ferriss2:11:30

        Mm-hmm.

    20. PADr. Peter Attia2:11:31

        This fake it until you make it, I was able to basically use that in my... You know, that's, the term fake it until you make it has such a negative connotation from Silicon Valley and companies like Theranos, but, but in psychology it can actually be pretty valuable, right? If you start to say something enough, you will believe it. We think about that a lot in the negative, but it works also in the positive.

    21. TFTim Ferriss2:11:54

        Mm-hmm.

    22. PADr. Peter Attia2:11:55

        And I think that in some ways, that one exercise became a very important brick in the wall of fundamentally altering my view of myself and fundamentally altering the stories I told myself.

    23. TFTim Ferriss2:12:11

        Hmm. And I must say, as someone who was there in your life for that period and also watching the steps that you took, including what you just described, I am so glad that you included the chapter in this book because I think a lot of people who would like to optimize lifespan and healthspan nonetheless find it easier to think about the maybe hard measurable edges of something that is physical versus that which is currently giving them the most suffering, which is some lack of equilibrium or a set of proper, I shouldn't say proper, constructive lenses through which to view life and themselves. So I think it's, it's a real gift, and not one without, I'm sure, some trepidation on your part to include this in the book. So I just wanted to commend and thank you for including that, 'cause I think it will help a lot of people.

    24. PADr. Peter Attia2:13:20

        Thanks so much.

    25. TFTim Ferriss2:13:21

        Yeah. I hope you feel good about it, Peter.

27. 2:13:24 – 2:16:20

    Parting thoughts.

    1. TFTim Ferriss2:13:24

       Peter, we've talked about a lot. The sun has come, the sun has gone. Is there anything else that you would like to mention before we close? Any requests to people? The book is Outlive: The Science and Art of Longevity. I never say this. Long-term listeners will know this. Go get the book. This is a very, very solid book that many years have gone into, not just in the writing, but in the living and experimenting and refining and changing of mind that is reflected in the sort of adaptability and principles in the book. So I do recommend everybody check out the book. Of course, earlymedical.com, peterattiamd.com. There are many other places on Instagram, @peterattiamd. Is there anything else that you would like to mention, Peter, before we wrap up?

    2. PADr. Peter Attia2:14:17

       No, other than just to, to really thank people. I think that there's a lot of noise out there in the world today, and I think that anyone who's gonna buy this book and devote the time to read it or listen to it on the audiobook- It's, this is not a two crapper, right? This is not a book you're gonna read on the toilet in, in taking two craps. So, [laughs] uh, I, I just wanna thank anybody who will-

    3. TFTim Ferriss2:14:38

       I've never heard that expression.

    4. PADr. Peter Attia2:14:39

       Oh, I think of all books as how many craps. It- every book is like, it's a four crapper.

    5. TFTim Ferriss2:14:43

       I know.

    6. PADr. Peter Attia2:14:43

       That's a two crapper. Yeah. So it's an amazing honor. Little things I've been doing for the book prep that would've ordinarily annoyed me to no end-

    7. TFTim Ferriss2:14:53

       Mm-hmm

    8. PADr. Peter Attia2:14:53

       ... haven't annoyed me at all, because I'm realizing that it is sort of a special thing that you have a relationship with someone you're not necessarily meeting, but they're doing something that is giving of themselves, which is taking the time to read this thing. And in exchange you're giving them something that's, that's, you know, hopefully valuable. So anyway, thank you for having me on the show, Tim, and thanks for people who are gonna maybe go out and get this thing.

    9. TFTim Ferriss2:15:20

       All right, guys. It's no two crapper. That's my quote on the back of the book. You'll find it featured prominently on Amazon. And Peter, Peter, congratulations, man. I know this has been a long time coming. I'm excited for you. I am even more excited for the people who will read this and hopefully derive from it some clarity and focus amidst an overwhelming amount of noise and bullshit out there. So I do see this as a very strong signal in a sea of noise, so I encourage people to check it out. Outlive: The Science and Art of Longevity. Dr. Peter Attia, nice to see you, man, and to be continued in person soon. Maybe we'll have those two drinks a piece with some red wine and some nice selects of axis deer from your freezer. And best of luck with the launch, man. Thanks for making the time.

    10. PADr. Peter Attia2:16:18

        Thanks, man. Appreciate it. Thank you so much.

Episode duration: 2:16:41