The Daily Habits To Live Longer & Happier! – Change Your Life One Tiny Step at a Time | Peter Attia

The Daily Habits To Live Longer & Happier! – Change Your Life One Tiny Step at a Time | Peter Attia



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Dr Peter Attia is a medical doctor and founder of the Early Medical Practice, a private clinic in America, which helps patients lengthen their lifespan while simultaneously improving their ‘healthspan’. He is also the author of the New York Times bestseller: Outlive: The Science and Art of Longevity

WATCH THE FULL CONVERSATIONS:

Stay Young Forever: The #1 Thing For Overall Health & Longevity Is This… | Peter Attia

Longevity Doctor: Fix These Diet & Lifestyle Habits To Prevent An Early Death | Peter Attia

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in your experience what are the common obstacles you find for people who are trying to make changes I think it depends on the changes but but if so so put that Nuance aside for the moment um I think in some cases the impediment to change is just inertia I mean sometimes it is difficult to say you know this is the way I kind of live my life these are my habits I want to create a new set of habits that requires sort of a willingness to to to do something different which for some people they don't want to break a habit so so I'll give you an example um I think they realize that doesn't sound very clear um if you tell a person um look you've got to go to bed an hour earlier and it would really be great if you didn't fall asleep on the couch watching TV because that hour of sleep that you're getting on the couch then you have to wake up and go into bed like that that's just lousy quality sleep well the the impediment to change isn't that they don't understand as you said that sleep is important but it's that they have a real habit around sitting on the couch to watch TV after you know to unwind and you're now basically saying well you're going to have to come up with a new way to unwind so it's the introduction of you know you're G to make one change but it actually requires several changes and I and I I think that sort of underlies a lot of things I also think there are you know certain things that people have to do that are not that Pleasant initially so for a person who's never exercised I think it's actually quite intimidating and initially unpleasant to exercise and you can tell them until you're blue in the face that once you get over kind of the initial challenge of this it's actually going to feel quite good you're actually going to appreciate the fact that it's not just beneficial for you in the long run which it is but even in the short run but they do have to take a bit of a leap of faith sometimes to do that um I think when it comes to changing behaviors for example such as food um sometimes realizing that changing the default environment of your food is very important requires a big leap forward so it's one thing to say look I want you to you know stop eating this way and start eating this way isn't simple as saying that it's well your pantry needs to change and the types of places you go for lunch need to change cuz you know you want the changes to be requiring less willpower and more automated Behavior yeah so I don't think I'm being very articulate when I'm saying this but I guess what I'm trying to say is it's usually not one change yeah it's usually multiple changes that have to be set up to make the beh behavior of Interest be more automatic yeah I I would say that very much Echoes mine experience I guess what I often think about with patients very similar to you I think is that all behaviors are therefore a reason they serve a role in our lives and I think often we try and change the behavior without understanding what was driving that so is the sugar you're craving at 9900 p.m. on the sofa really physical hunger or is it emotional hunger you know is it that you've had a crap day is it that you've fallen out with your partner and that that bit of sugar is going to help you because if it is then you might need a different strategy is it that you're you feel lonely and instead of the sugar maybe you want uh a phone call with you friends is it stress maybe you want a relaxing bath rather than that Sugar whatever it might be and so I would say that's one of the key things I've I've learned over my career is yeah you can change the behavior without addressing that but it tends to be shortlived classically new year new you you know fine spinning four times a week every week for the whole year know well you do it for two weeks when your motivation is high and then suddenly you've had that bad day at work and you need to pick the kids up and whatever ah you know what that's too hard so is that something you spend time within your practice trying to understand because look the behaviors are great and I want to talk about more of these behaviors that we want people to do but it's often not the behavior it's it's the impediment to that behavior that I find I spent a lot of time with with patience I I think we do as well and um I think that that is the I think that is the the biggest challenge and and certainly within a year of being in our practice there's no patient who's at a loss for what they should be doing right that's um you know that's there's not much of a mystery it'll be it might be a mystery when they come in there might truly be some confusion about you know the optimal strategy around exercise or whatever um you know one of the things that um we try to remind folks I just think of it with the example you gave is um try not to have two backto back misses yeah right so the the example you gave there of so you for for two weeks you're doing your four spin classes a week and it's all going well and then you have that bad day I think that a lot of people get into a negative spiral when they punish themselves for that bad day and they feel ashamed that they've missed their workout something that they set they were set themselves set theel you know set themselves to do and sort of that shame becomes the more dominant emotion as they are getting ready to have that next workout and it becomes easier to miss that next workout and instead what I think you want to try is say look you have that bad meal that you said you weren't going to have you miss that workout you do something that is kind of off your path um just give yourself a total pass with no judgment and just say yeah it's really hard like if this was easy you would have done it last year or the year before or but just get it right the next one just make sure the next meal is right make sure the next workout happens um and I I even find this as important myself I mean I I and and I tend to you know people would look at me and assume I'm sort of a a beacon of willpower um but it's not always true and I I still have to be very uh non-judgmental and sort of remind myself when I slip that it's okay and let's just try it to slip tomorrow is that a new thing you've had to learn in general absolutely um it's become more relevant as I've become older so um you know I think when I was younger and even more selfish there were never reasons for me to deviate but now with a family with other responsibilities there are plenty of reasons for me to deviate and I deem those better uses of my time sometimes and uh as a result of that I I do sometimes battle myself thinking what's happened to you like yeah look at how much you're slacking off and in in you know whatever regard you're talking about but but yeah I I think I'm much more compassionate with myself today than I used to be yeah snap I mean I I would very much berate myself in the past if I said I was going to do something and I didn't uh there was quite a lot of negative selft talk going on and you realize it's just never that helpful if shame or guilt is that underlying emotion I just don't think it's sustainable in the long term it will always catch you out at some point certainly that's what I felt by the way that's a whole other so so so going back to the what are the impediments to the behavior change I find that there's another phenotype that I see in my practice which is um um another manifestation of of of trauma right which is uh basically the individual who's completely incapable of taking care of themselves or putting themselves ahead of others yeah so I see this phenotype more commonly in females um and I see this as often you know um a mother who's you know doing a lot of heroic stuff so probably working really hard in a job uh probably puts her husband and kids needs ahead of her own but she does so at such a detriment to her own health yeah and she keeps you know she you know it's like so she sort of understands that her health is suffering but almost feels like it's her place to suffer and she can't make that exception and and you know you'll say look like you've got to carve out an hour a day for yourself to do these things and she says yeah I know I should but and then there's a string of excuses but you realize that deep down what's going on is like there's a form of self-punishment happening and I'm not saying that that's true of every mother who's out there working and busting her butt but I'm just saying in the in the examples that I've seen in my practice I really attribute this to kind of a maladaptive Behavior around trauma and um and that's another example of where I you know I I I would describe that as sort of an emotional health failure that's cascading into physical health failure yeah I would say that one of the things I've learned and and it plays into what you just said about this trauma piece a lot of people these days have I would call them lowgrade addictions whether it be sugar or social media or online shopping or scrolling online whatever W which which gets in the way of other behaviors because there's a lot of behaviors that people could do to optimize their long Jey but I think this is a really important piece you know why is it that people can't do those behaviors why do do a lot of people perceive themselves to not have time and I mean I very much like Gabel mate's um definition of addiction which is again if I butcher it slightly please forgive me but something it's got these three components uh any Behavior or substance that you crave that either relieves pain or gives you pleasure that you are unable to stop doing or give up despite negative consequences right so through that lens of looking at addiction I would say many of us most of us all of us have some level of addiction and I'm interested do you do you find that a relevant area to go into with your patients do you see these low-grade addictions as getting in the way if them making potentially more helpful changes when it comes to their longevity yes but I would take a step even further back from that and say forget about the impact of these Addictions on their capacity to exercise or eat correctly or sleep correctly I would say just talk about the impact of those Addictions on their relationships um and and and I I think that's kind of the interesting thing about about trauma which usually on some level underpins some of these behaviors and by the way I think that that term is so loaded and people think trauma has to be Big T trauma but but really little te trauma can be just as um uh just as impactful sure um but but not kind of dealing with those things and not understanding that most of those things produce really wonderful adaptations but as collateral they sometimes have maladaptive behaviors yeah and failing to deal with those things can have the impact on the physical side which we talk about right it's usually going to come in the form of failing to engage in self-care through those behaviors those positive behaviors but it can also be pretty disruptive to your interpersonal relations and and I think if your interpersonal relationships are compromised your quality of life is compromised your your your happiness is compromised your joy is compromised and um you know honestly I think that's just as as problematic so to your question I think the way to approach that with patients is probably to find out where they're sensing the discomfort the most yeah and I I think that varies by individuals so I think there's some people who are sensing that discomfort the most Visa the behaviors that they're not engaging in correctly I.E I'm not eating well enough I'm not exercising I'm not taking care of myself in the physical sense whereas I think for others the the the way in which they're going to um face up to that is is going to come through the the destruction or damage on their relationships be it with their spouse their kids their friends co-workers it's when you when you really delve into this area and I know you've been on a personal Journey yourself with this as have I it's more and more about emotional health I think it's not that physical health doesn't matter of course it does and you know being physically healthier of course helps us with our emotional health as well but I kind of feel that the emotional health piece yes it drives better selfcare yes it helps your relationships but you know there's quite a lot of research now showing that I've got to be very careful how I word this because I'm absolutely not putting blame on people but there are strong associations now between people who hold on to negative emotions who hold on to anger and resentment who are unable to forgive and the risk of water immune disease and again I'm not putting blame on people there are associations in the literature if I look at my own practice my non NHS practice was largely filled with people with autoimmune disease a lot of women I would see these kind of personality traits a lot I don't know if you're familiar with Fred luskin's work at Stanford about um forgiveness and the ability to forgive on blood pressure m really really interesting and I guess I followed you for years Peter and so you strike me as someone who you you you've openly shared things that you measure in your own life right for for many years I often think about that that phrase that you know not everything that we measure matters and not not everything that matters can be measured exactly so yes we can measure key metrics and we spoke about some of them uh the first time you came on my show but there were kind of some other sort of unmeasurable which I find more and more are impactful for health I'm thinking about specifically to one patient I think she was 48 she had mildly elevated blood pressure I can't remember exact numbers but I'm going to guess it was in the region of 135 to 140 over 90 something like that and we for six months we're trying to make changes with Al Lia she transformed her diet she started exercising you know she started to prioritize her sleep yeah I couldn't get it to budge I couldn't help her get it to budge and I was and we mentioned it properly we did 24-hour monitoring and I I thought what am I missing here now of course some people are going to be resistant maybe it needs phal but I just felt from talking to her that she was holding on to a lot of Banger and it turns out as I got to know her more that she actually was she had split up with her ex-husband who had cheated on her and she couldn't let go right she ABS just could not let go and we spoke a bit about forgiveness and the importance of doing that and letting go and I w't go into everything that we did but essentially over the next few months she basically learned the skill of forgiveness she uh managed to let go of the anger she felt and her blood pressure normalized now that's an nals one I'm aware of that but I'm sharing that with you because these things really teach me that there are all kinds of inputs into a human that manifest in their physical health and I didn't learn that stuff at Medical School I've just kind of picked it up through just observing and then I go to the literature and see well that that is supportive research now do we have the same quality of evidence for that as we might do for a particular form of exercise for l blood pressure no probably not but on an individual level when I have someone in front of me I'm always trying to think which inputs here can I manipulate what could I be missing here and and you're someone I I respect incredibly and so this feels like the softer side to medicine but I feel it's just as important as the harder side and I I I guess I just love your thoughts and perspective on areas like that oh I I I I would agreee with that completely uh in every regard right meaning that do I think that that matters absolutely do I think that it's very difficult to quantify if not impossible absolutely um to me the biggest question is um you know how do you teach it right so so how how did you get that patient uh who I think most people wouldn't fault her if she basically said I'm going to carry this you know ax to grind for the rest of my life most people would say understood yeah get it um so H how how did you work with her to first of all convince her that it was worth trying to to uh to to forgive her her ex and then secondly how did how did she actually go about doing that yeah so firstly I believe in informed consent so I explained her the situation I explained the risks of not treating that blood pressure in terms of her long-term he and I explain what the options were I also had built up a really good rapport with her I got to know her this is one of the beauties that it's hard these days to be fair but certainly a few years ago there was still that continuity in primary care where you would in the NHS here where you would get to know someone you would get to know their family you would actually get to see who they were in in in their lives in a way that you don't always get with hospitle medicine so I had built up a really good rapport with her she trusted me so I don't go there with every patient I just got a sense from her so you know when the time was right in a consultation when I felt she was open to I said listen you've done incredible work with all the changes you made to your lifestyle I would have expected to see some change here not always but usually my feeling is I I picked up a couple of things from me that I think maybe at play here would it be okay if I go through someone them with you were you interested and I broached it and the first time I broached it you know brick wall she wasn't willing to go there but I would like to see patients regularly even though it was just 10 minutes I would often get them back every few weeks I like to follow them up and talk to them and it it got to the point where she was open she goes I said look we can put your medication and or we can try this because I think this may help your blood pressure but frankly I think it's going to help many other aspects in your life as well like if you hold on to this and I understand and I explained to her that forgiveness would be not for her ex-husband it would be for her and I can't remember the exact exercise I I think I I wrote this out on my third book but it was a forgiveness exercise and just a four-step process of asking her you know what exactly what was the emotion she was holding on to what benefit that gave her is there a possibility that you can see it um from your ex-husband's perspective you know what might have been going on in their mind and are you willing to carry this for the rest of your life because you essentially and I I can't remember the language I you said actually that means your husband still has power over you today your ex-husband an act that he did it still affects you in your day today so again I don't want to I don't want to sort of derail the entire podcast onto this case but it wasn't just a quick fix it took time it took trust it took her trying it a little bit coming back I think I often to refer her to a psychotherapist I don't think she wanted to she'd build up trust with me but the point is is that yes it was difficult but my belief is that not only did that help her with her blood pressure that's going to reap dividends in multiple aspects of her life emotionally and physically for years to come I'm convinced of that and I agree with you I think there's a subtle point there which is I think it's a better health outcome than just pharmacologically addressing it so if you had just given her an Ace inhibitor or an ARB you would have fixed her blood pressure but you probably wouldn't have fixed the underlying sympathetic tone the hypercortisolemia that was still going to have negative Health consequences and I've done that for many patients right I've I've done what you did I've put them on the ace right so I'm not trying to say I do that every time don't but I'm saying in her case what I think is a win is uh it it's it's the blood pressure got fixed but that's almost a biomarker of the actual problem getting fixed and with it her risk of many things is going down that are you know accounted for by the hypercortisolemia and that increased sympathetic tone and the increased blood pressure yeah I just find that so fascinating and then when I was thinking this morning you know what I'm going to talk to Peter about you know one thing that fascinates me deeply is your practice it sounds like like very few other practices that exist maybe globally now we touched on this briefly last time about our different experiences you know you in the US in a private system me in the UK in a publicly funded system and how that would affect our experience and potentially our viewpoints as doctors and I'm fascinated as to what people coming to see you with because typically in the HS we acknowledged last time that we're pretty bad at real prevention in medicine the current way it's practiced medicine 2.0 compared to Medicine 3.0 as you outline in your book right but people in the UK I would say and in America I'm sure typically go to see their doctor with a problem right doctor I've got pain here this hurts you know they're coming in with a problem that they want you to solve are your patients coming in to see you and your team with a problem or are they coming in to say Hey listen I want to make sure my marginal decade is as good as it can be Peter can you help me yeah so if you if you compare I think maybe a note that you would write when you see your patient it probably starts with a chief complaint yeah right it would probably start with Mrs Smith came to see me today with a chief complaint of bloating or reflux or pain here or there um on our first meeting with a patient the um the the note actually begins with their goals and there we break the goals into two brackets so it's uh marginal decade goals and goals for the next 12 months yeah I I love it I think it's just it's just a wonderful exploration of what might be possible what might healthare real preventive Healthcare look like and yes you say it's a luxury but I guess you've created that you've created the opportunity for people to go and experience that and I guess you've learned so much through doing that and creating that because often we don't have the luxury certainly in the National Health Service of doing a lot of the tests you do having access to that data what do you say because I was thinking okay I don't think the test is the biggest limitation really I don't um and we actually talk about this with our patients early on like in the first month or so um in fact the first time we do a blood test review with a patient we review their bloods I sort of give a a soliloquy that every patient gets the first time and the gist of it is something like this look um there are there are several metrics that we're going to be paying attention to in in the duration of your time in this practice so you might be in this practice for two years you might be in this practice for 10 years we don't know but you're going to get used to a drill and a Cadence with which we pay attention to things and most patients are coming into this practice with an over indexing on blood test because that's kind of you know in their previous relationships with doctors that's the thing that doctors are most paying attention to and we say look that's fine like you know we're going to do blood test and we're going to talk about that here today that's what we're here to talk about but you should understand that your blood test is only about I don't know one of 30 to 40 inputs that we put into our risk assessment model so your family history which we talked about last week and we you know the reason we sent you home with a 10-page packet to fill out is because we really want to know your family history um and you know you're going to we're going to do a movement assessment that's going to take two hours and eventually a strength assessment that'll take a couple of hours and a V2 Max test and a Zone 2 test and a dexa scan and a liquid biopsy like there's a lot of things and yes we want to know your apob and your you know ug glycemic you know we'll do an ogtt Etc so the labs are only one of again 30 things we look at and by the way the labs have huge blind spots like the labs are really good at helping us predict your risk of cardiovascular disease when coupled with understanding your blood pressure and a few other things um they're not really good at helping us understand your long-term risk of cancer even your immediate risk of cancer I mean there's just a stochastic process to that that outside of measuring metabolic Health this doesn't really tell us if you have cancer or not um so we sort of almost deemphasize the labs and I think the biggest impediment um from a Time perspective is is actually on the is on the movement stuff is on the exercise stuff is on nutrition sleep it's it's that's the challenge you'd have in 10 minutes right that's why 10 minutes can't simply make that happen and and and people say to me you know Peter why aren't you you know scaling this like why aren't there a hundred other practices doing this and I think that's the challenge it's how do you scale those other pieces that do require the bespoke nature of of inter interaction with with a with an expert in that area and we're doing some things I mean we're building courses and and video stuff along that line but um it it it's it's it's just going to take other doctors saying I want to learn this stuff well enough that I can then be the conduit of this information um but I'll tell you there I mean in the UK you guys are further ahead of the us and that you already consider apob for example to be uh an appropriate metric for measuring risk for asked is you consider apob in the UK to be superior to ldlc the the US is still backwards on that one I think also what your model is showing is true prevention and actually without getting into policy and why the healthcare system is set it the way it is just taking a quick break to give a shout out to Vivo barefoot shoes now I've been a huge fan of Vivo barfoots for over 10 years now well before they started supporting my podcast they are the only shoes that I wear and they really have had a huge impact on my own life and the lives of many of my patients you see when people start wearing Minimalist Shoes like vivos you can see improvements in things like back pain hip pain knee pain foot pain even things like planta fasciitis can often get better and scientific research shows us that just wearing Vios for about 4 months or so improves the strength in your feet by over 60 % which is absolutely incredible one thing people don't realize about these shoes is just how flexible they are which allows your feet to do what your feet naturally want to do rather than the shoe dictating your foot's movement Vivo Barefoot are giving my audience a 15% off onetime code when you make your first order and they make it really easy for you to give them a try they give a 100 day trial for new customers so if you don't like them you just send them back for a full refund I'm a huge fan I really hope you take advantage of this offer to get your 15% off codes all you need to do is go to Vivo barfoot.co.nz everyone despite The Upfront cost it is very clear or I guess without running numbers how can I say this it would appear to be very clear that you will save a ton of money at the back end like if well it's is why by the way people always ask me can we Institute a system like this in the US and I actually say it's much easier to Institute this in a single-payer system um can you just expand what that term Single Payer means if someone doesn't yeah so A Single Payer system would be like the NHS where you have the government as the only payer the government is the insurer yeah and why is that the case so A Single Payer system by definition implies the government is is paying we don't have that in the United States for everyone we have we have something called the center of Medicaid services CMS that provides um services to people over 65 and something called Medicaid for people who have you know qualify for very low income but the majority of people in the United States who have health insurance have it through a private insurance carrier and that private insurance carrier will only be insuring them for a short period of time and it's actually it's even more complicated in the US because depending on the size of your employer sometimes the employer is the insurance uh risk Bearer but it's done through the administrative Services of an insurance company all of this is to say they don't really have the incentive to pay money today when you're 25 and 30 to prevent complications when you're 60 or 65 because they won't be the ones insuring you then you'll have a different employer or a different insurance company so if you think about the NHS though or any Single Payer system um there really is an incentive to invest wisely when people are young and healthy to spend a little bit more because you still as the Single Payer in this case the government own the risk of that life down the line yeah so it's in many ways much more logical to consider medicine 3.0 in the context of a single-payer system than it is in a multi-payer system no that makes complete sense I guess one of the obstacles to that um is that the National Health Service is such a political Hot Potato that really there doesn't appear to be this 203- year Vision more there's an election in two years so what do I need to do with the NHS to make sure that I get reelected yeah which is fundamentally going to be problematic because decisions are always going to have a bias to shortterm Y as opposed to longterm and of course these things require an upfront investment that is more painful in the short term you reap the benefits in the long term just to finish off on your practice given that it is private given that um there's a cost element to it presumably and please correct me if I've got this wrong presumably it's only going to be people with a certain amount of resource who can actually access that and then in a capitalist system a lot of the people who end up with that resource in my experience are kind of type A personalities who have worked hard often not always often felt that there was something to prove right which drives them to get incredible success in the system which can reap rewards I don't know if that's fair to say or not of course every patient is different but then if that is the case are there certain patterns you see in those individuals and then I guess what can we learn from that if because a lot of people like your show listen to this show who may not have those resources so I'm always interested this is a great model of a practice what can we learn from that yeah I mean I think I think as a as a generalization that's probably a fair characterization um of course there are many exceptions to it so it's you know it's one has to take that with a grain of salt um and what's interesting is something that you alluded to earlier right I think that sometimes the most high achieving hyper performing people are doing it because they have something to prove and sometimes that need to have something to prove comes with other baggage that can undermine your health um both directly and indirectly and so I realize that statistically speaking more affluence translates to more health yeah but that's not true Beyond a certain point in other words it's true that having you know an income of 50,000 a year will produce a better health outcome than having an income of 10,000 pounds per year um and maybe having an income of 100,000 pounds per year will give you a better health outcome than having an income of 50,000 pounds per year possibly I'm not sure but what's absolutely not true in my experience is having an income of £50 million pound per year versus 100,000 per year I don't see any difference in health outcomes at that level and in fact the person with the you know multi- multi uh million pound income uh often comes with other problems yeah um and so you know one needs to be careful what one wishes for and I say that just as much to myself as to others um and I think one just has to accept the fact that um you only have really responsibility and accountability for your own choices and your own behaviors and I I really think that time is the most important parameter in this game it's really not about resources as Financial Resources as much as it is about time and that's an example of where yeah that person who's barely making it can often be in a situation where they don't have time either you know they're they're scrounging so many things together to make it work but um but you know you you brought up exercise a moment ago I mean if a person could spend an hour a day exercising I mean they're going to be healthier than the richest person on the planet who isn't doing that yeah yeah appreci who has all the fancy doctors who has all the fancy clinics who does all the executive physics I mean none of that stuff will matter if they're not taking care of themselves and I've seen people across the Spectrum and the the correlation is very loose yeah just to finish off then Peter you touched and maybe we don't have time to really go into this in detail but given that women have lower easn levels post manopause and I know this this is quite a contentious area in terms of does every woman need hormones after menopause for brain protection cognitive protection muscles are you able to give to such a nuanced topic sort of quick over overview summary does every woman need it in your view well um it is a very complicated topic and it's one I've devoted a couple of podcasts and a lot of writing to um it is contentious very contentious certainly I found it to be it it is contentious unfortunately it's contentious for the wrong reasons meaning it's all predicated on bad information right so all of this controversy around hormone replacement therapy stems from a trial called The Women's Health Initiative that was published 21 years ago that you know very erroneously um sort of permitted the media to misunderstand and misinterpret and and propagate um and basically the conclusion of that study was that estrogen caused breast cancer uh when in fact the the experiment showed the exact opposite so the Women's Health Initiative actually showed that estrogen was protective Against Breast Cancer but estrogen combined with synthetic progesterone did slightly increase the risk of breast cancer but not mortality from breast cancer when I say slightly increase the risk I mean one case per thousand one there was one additional case per thousand of breast cancer zero additional breast cancer deaths associated with that in the estrogen group alone meaning women who didn't take estrogen with MPA the synthetic progesterone there was a reduction in breast cancer that was both true when the trial was halted at 5 years and subsequently when the data were evaluated 15 16 17 years later so again just a a grotesque misunderstanding of the literature um there are many reasons to consider estrogen um some of those have to do with symptoms so Vaso symptoms um and I would argue that any woman who is experiencing Vaso symptoms such as hot flashes and night sweats um shouldn't have to suffer through those and therefore I think hormone replacement therapy completely makes sense in that context where I think it gets a bit more nuanced is what about women who were not experiencing vasomotor symptoms and what about women who are through the period of vasomotor symptoms so let's say they went through menopause at 50 and they're now 60 if they stopped the hormone replacement therapy presumably they would stop they would not have symptoms anymore but they would also lose the protective benefits of estrogen on their bones the truth of it is we don't have great data on that and we never will no one will repeat the experiment to find out the answer to that but at least in our system I believe that it's much easier to screen for breast cancer than it is to treat osteoporosis and um I think each woman has to be sort of I mean I hate to say it it's such an obvious cliche but each woman needs to be treated individually and you you you basically have to look at what are the symptoms of estrogen withdrawal and if they're trivial if a woman experiences no issues with estrogen withdrawal and she's really afraid of the consequences of Lifetime estrogen then that's probably the choice for her I was in a a practice an NHS practice in an area of very low socio economic status lot of low income a lot of poverty and there was someone who you know was coming in was all kinds of issues which I was trying to help him with and you know he was struggling for time and was saying look I I I don't have time to do this I'm busy I'm doing this but when we actually figured it all out and actually went through how he spent his time when he was not at work he was doing things like going for three or four shops a week to different shops to save money he was uh driving I think 20 minutes out of town to get cheaper petrol and in the context of everything I won't go through the whole story but essentially we figured out that he was saving very little money but spending about 4 hours a week for that and so we came up with a like a 4 week challenge say okay for these four weeks instead of saving that and I appreciate the money's tight and he agreed to this it wasn't me sort of cajoling him into doing something he didn't want to do I said with that time saving you could go for a walk you could spend time with your kids you could do all kinds of other things and I I kid you not Peter that one chain literally over the course of 6 to 12 months starts to transform his health because he suddenly realized wait a minute everything in life has a cost and actually the cost of actually just going to the petrol pump down the roads which is a bit more expensive but actually it gives me so much more time to look after myself and he you know a year later the guy had lost weight he's got a better relationship with his children with his wife simply because he needed somebody outside of him to help him understand that actually everything in life has a cost we're often simply not weighing it up yeah look that's a beautiful example um and and it's uh I think it's something that you as you point out it's not always easy for you to see it yourself when you're the one in it it's it's this is where it really helps uh he was lucky that he had a doctor who with the limited system of having 10 minutes with a patient because most I think most doctors wouldn't have necessarily what the ability you had which is to say hey um I'm going to think beyond the the immediate problem in front of me which is that your blood pressure is too high and you're overweight and I'm going to start thinking about this from the standpoint of your life so he's very fortunate that that he had that and you know unfortunately I think that that's that's probably not common right I think I think many of us go through life making these tradeoffs that in the big picture are uh quite irrational so we mentioned APO B right so in terms of the things that you feel that many of us should be looking at and then potentially treating aggressively if it's elevated or if we have a strong family history or whatever it might be and and and to be clear you you set this out really beautifully in the book for people who want to dive deep that's one thing that we've mentioned that not everyone can have have access to both in the US I think and here but before we move on from apob if someone cannot get that and all they have available to them is a standard lipid panel of total cholesterol triglycerides LDL and HDL how would you advise them to look at that with a view to assessing their risk well as I said non-hdl cholesterol which you can calculate by taking total cholesterol and subtracting out HDL cholesterol that gives you a number um that is you know that's a poor man's version of apob and it's a better predictor than LDL cholesterol of risk and so you know I assume in the UK your units are Millo not milligrams per deciliter so I'm not I'm not familiar with the unit system as well but there are readily available tables that will demonstrate percentiles yeah and so what we suggest is that a young person really should be below the 20th percentile at or below the 20th percentile and the younger you are the less aggressive you need to be because this is sort of an area under the Curve problem so it's really about lifetime exposure just as blood pressure is right you know if you if you have um high blood pressure even mildly elevated for a very long period of time it's going to cause you know proportionally similar damage to a person who has higher blood pressure but over a shorter period of time and similarly with apob you know if you start lowering this when a person is in their 30s you don't have to make an enormous change outside of cases where people have familial hyperchol or things like that um versus when somebody shows up in their 50 and they already have evidence of aerosis on a CT scan uh then you're going to have to be much much more aggressive so you know I mean I would just say directionally somebody who has any evidence of atherosclerosis you're you're basically now treating them as a very high-risk secondary prevention case even if they have not had an MI which is normally what we would use to move into the world of secondary prevention if a person has Cal app on a ctam or CT um coronary CT that's effectively secondary prevention we would want that non-hdl cholesterol or Elio cholesterol below the fifth percentile that's such a good point Pizza which I I think many many people haven't really grasp that if you've already got signs you don't have to wait it's it's that smoking analogy again you know wait until you're off the cliff you know wait until you've had the heart attack okay now we know what we're dealing with now we can Implement secondary prevention it's kind of like no you know we we don't need to wait for that moment it's it's so basic and obvious when you lay it out like that it is quite remarkable that we seem to have gotten to a system where we we don't treat early and I I get it I understand the pressures within the medical system I understand why we've ended up uh working like this why of course you set out the case we need to upgrade medicine now rethink medicine um but that's a that's a really really good point do have numbers that you look for I know don't worry about the UK units people can easily convert are there you know do you have numbers with these ratios like triglyceride to HDL ratio do you like to see it below a certain amount for example well it's important to understand that while the ratio of triglyceride to HDL cholesterol um is suggestive of insulin resistance it has no bearing on atherosclerosis risk uh in fact um I I think we we wrote about this in our newsletter we have a newsletter that comes out every Sunday and it it usually goes pretty deep into these topics and um we did a newsletter on this particular issue around the value of knowing triglyceride level um we certainly pay attention to it and we're alarmed anytime the triglycerides are over about 100 milligrams per deciliter that tends to be alarming and certainly If the ratio of triglyceride cholesterol triglyceride to HDL cholesterol is above about two we also tend to think that that's a red flag even though most people would say three four or even five would be the threshold we think anything over two is a red flag as a ratio of triglyceride HL cholesterol but here's the interesting thing once you normalize for apob there is no residual remaining predictive value of htl cholesterol triglyceride total cholesterol those things completely become irrelevant once you know apob and basically non-hdl cholesterol as well so in other words once you have the non-hdl non-hdl cholesterol level pegged that captures all of your lipid risk now the only exception to that is LP little a but we can talk about that separately So based on what you've just said in a hypothetical scenario where people were given an option say you can have one test to measure your risk of atherosclerosis one blood test yeah and you had to pick and I appreciate we're not in that scenario but as a thought experiment you would say that one test should be a yeah there's no ambiguity about this it's it's the literature is overwhelmingly uh in fact I'm not aware of a single study that would suggest that there is a superior lipid biomarker to apop uh there are some studies that would suggest that non-hdl cholesterol is almost as good but on balance when you look at the overall all body of literature it is unambiguous that apop is the superior biomarker but I I want to be clear and I don't want us to get hung up on this because I know your audience might not have access to apob so I don't want perfect to be the enemy of good yeah if you don't have access to apob that's okay the the the jugular Point here is know your non-hdl cholesterol know your LDL cholesterol and manage those aggressively and the reason that non that non-hdl cholesterol is better than LDL cholesterol is it includes vldl cholesterol by proxy and therefore it includes the negative impact of excess triglycerides so you asked a question earlier about triglycerides and you're absolutely correct elevated triglycerides are a risk for cardiovascular disease and they're a risk that is not captured by the LDL cholesterol but they are captured in the vldl cholesterol and that's why apob captures them both because apob is the concentration of all atherogenic particles and so as the triglyceride level goes up so too do the number of lipid transporting lipoproteins because they now have to make way not just for the cholesterol that they're trying to carry back to the liver but also this High burden of triglyceride and that's again why apob is a superior metric but if you don't know apob and you don't know for some reason non-hdl cholesterol then yes you do need to know triglyceride and LDL cholesterol to capture the full risk before we move on from this topic thank you for summarizing that Peter for people who uh don't have access but let's say by whatever means you found out that you have higher levels of apob or non-hdl cholesterol than you would ideally want you've mentioned there are some pharmaceutical interventions that one can use what sort of Lifestyle interventions can people do to to bring that down the most important ones come down to those that reduce triglycerides because of everything I just said a moment ago namely that the higher the triglyceride the more lipoproteins you need to carry them and namely that's the vldl the very low density lipoprotein which ultimately becomes an l a low density lipoprotein so the question then becomes what do you need to do to lower triglycerides so the people for whom dietary interventions are most potent at lipid lowering are the people who have the highest triglyceride level as a general rule so when I see people that show up with very elevated LDL cholesterol apob and very low to normal trigly erides we don't waste any time with dietary intervention with one exception which I'll come back to in a moment but for the most part we recognize a genetic defect usually at the level of the LDL receptor that is responsible for this problem and it must be addressed pharmacologically so but let's go back to where we still see a lot of room for um Intervention which is a person with elevated apob or LDL cholesterol nonl cholesterol and also very elevated triglycerides so the easiest solution here is typically carbohydrate restriction so carbohydrate restriction uh generally is the quickest path to reducing triglycerides but it comes with a catch and that is carbohydrate restriction usually means increasing fat consumption and in susceptible individuals increasing fat consumption especially saturated fat consumption will via a totally different mechanism increase cholesterol production and that's what I was actually referring to earlier which is the other dietary thing you have to always be mindful of when you're staring down the barrel a very elevated ldo cholesterol or apob is what is this person's consumption of dietary fat and in particular dietary saturated fat yeah if a person is sensitive to that they will increase cholesterol synthesis and dietary fat High degrees of saturated fat will impair LDL clearance from circulation via the liver yeah it's a great point and I would agree in in in my experience as well there there's nothing faster and more effective to bring triglycerides down than some form of carbohydrate restriction but as you say you've got to not just look at the triglycerides in isolation because you don't know what else might be going on as a consequence of that it's another example of the question you asked earlier you do something thing on the lifestyle you you you cut carbohydrates and fix the triglyceride problem but if you do it by mainlining coconut oil or whatever your saturated fat dour is you'll drive apob up through the roof you're probably worse net off than you were at the outset everything has a yin and a Yang yeah and there's obviously this big online debate over how much does that matter on an aggressive let's say a low carbohydrate diet for example there's you know I've I'm sure you have been involved with this seen it all like the conversations around how much does this really matter if the hscp the marker of inflammation is down you know how much do we need to worry about other things potentially going up and you know I don't think this question is as nuanced as those proponents would argue uh it's no more Nuance than you saying uh how much should a smoker worry about smoking if they're otherwise healthy and fit maybe less than a non-smoker uh maybe less than a smoker who is not healthy and fit but does anything about the fitness of or otherwise good health of that smoker diminish the causality of smoking in respect to cancer no yeah and similarly if you tell me that a person is on a low carbohydrate diet and that they're insulin sensitive and their inflammation is low but their apob or LDL cholesterol is still through the roof that doesn't change the fact that they're still at risk as a result of that so again this is why causality matters so much the person that has familial hyper cholesterolemia can be completely metabolically healthy in fact many of them are right you know you diagnose this in a child who's 15 20 years old they're thin they're lean they're healthy their hemoglobin A1c is 5% their biomarkers are pristine yet they have premature atherosclerosis because of Lifetime exposure to LDL cholesterol of 200 milligrams per de so I think that the people who are suggesting that just because you're on a low carbohydrate diet and your other biomarkers are fine but you know and you can ignore your LDL cholesterol I think those people are playing a very dangerous game of Russian Roulette and I hope that people who are paying attention to those people um get a broader aperture on their view of Health blood pressure of course is also a very important uh metric for us to pay attention to and of course for many years now there's been home blood pressure cuffs available right so whether your doctor is doing it or not and of course there are some pretty big limitations of rushing uh getting your car parts rushing in and actually hey yeah take my blood pressure doc of course there's some real problems there but speak a little bit about blood pressure because what I love about addressing blood pressure is that first of all in terms of us being blind to what is going on inside our bodies and then somehow at 50 or 60 running into problems blood pressure is something that we could get on top of pretty early if we started paying attention so how do you view blood pressure how do you frame it with your patients um yeah and then we can maybe dig into treatment potentially depending on where we go with this yeah I'm really glad you bring this up there are a handful of regrets I have in writing the book regrets is the wrong word there's nothing that could have been done about it but I guess I would say there are a handful of topics that I wanted to go much much deeper into but as you know the book is almost 500 pages there was simply no margin to go longer so so this book is 60,000 words shorter than the previous version of this book in other words an entire book was stripped out of this book and one of the topics that I really wish I could have put more energy into is this exact topic and I I would argue this is just as important as the apob discussion but for a slightly different reason sorry to interrupt if you're enjoying this video and want to learn more you can download my free special guide containing six simple breathing practices that will help you calm your mind lower stress and improve your energy to get a hold of this guide all you have to do is click on the link in the description box below and the reason is here you have a physiologic parameter that not only shortens your length when it comes to cardiovascular disease but also does so with respect to Alzheimer's disease and Dementia by the way we didn't talk about that with apob but apob is also probably lowering apob is I would say one of the three most potent interventions you have to avoid dementia and Alzheimer's disease we we maybe bracket that and come back to that that doesn't get nearly enough attention right there are you know along with exercise reducing lipids is unambiguous ly the shest way to prevent Alzheimer's disease and dementia but so too is lowering blood pressure and the other thing that doesn't get nearly as much attention is the impact of elevated blood pressure on kidney function and how significant this becomes in an aging population and while you know this rarely gets a 40 50 or even 60 year old into trouble it starts to become very problematic when people are in their 70s and 80s and when you have very comp compromised kidney function one it makes it much less likely that you're going to live to say 90 and also you become far more susceptible to toxins that you know your kidney would normally filter out when your kidney is functioning at a quarter of its capacity so blood pressure as you said is partially Complicated by the fact that we as a medical community don't do a great job measuring it in our patients so you very accurately uded to the exact problem right which is patient you know Parks the car has to run up the stairs sit in the you know Reception Area get quickly shuttled back have their blood pressure checked with an automated cuff and that number doesn't tell us much I mean we know from the Sprint trial that there is a really clear protocol for how to measure blood pressure and you need to be sitting comfortably with your legs uncrossed not speaking for five minutes the automated cuff or the manual cuff needs to be placed in exactly the right way such that the marking on the cuff aligns with the brachial artery and such that the cuff is at the level of the right atrium I.E where the venne Hava Superior and inferior empty into the heart you know I think it's interesting and I do this all the time just to show people take a blood pressure reading with your arm significantly above or below your heart and you will be amazed at the difference in pressure it is very sensitive to this finding for this reason we typically recommend that our patients get a very highquality Monitor and we typically direct them to two or three that we fancy and let them buy it on Amazon or at their local drugstore we give them a log electronically and we ask that they check their blood pressure twice a day in the morning in in the afternoon or evening according to this protocol and we don't even make assessments on this until we have at least two weeks of data but those data now we can believe we can trust those data and now we know if those numbers average above 120 over 80 we need to take action because again this is where the largest most well-conducted blood pressure studies make it abundantly clear that treating either with lifestyle or phac te ology to better than 120 over 80 has significant benefits and outcomes over even 130 over 85 where we used to historically consider the upper limit of normal yeah it's such a good point measuring it correctly of course it's really important otherwise people can go out buy something from the local drug store try and take ownership of their health and then start to stress themselves out that actually whoa my blood pressure is really really high this a couple of couple of things there for me uh to to discuss Peter one of them is trackers in general because certainly as someone who's observed you online for uh a number of years you've been pretty open with what you track you've shared lots of times about the sort of things that you do track and of course not everyone is pro trackers and um my view is is that it often depends on the personality type in terms of you know I have had patients in the past let's say 10 years ago for example um I seem to recall that maybe you know and I say 50% of patients this is just you know a rough guess but basically around half of my patients when they would say should I get a blood pressure Mon and said would it be helpful I said hey sure why don't you pick one up and um you know let's let's sort of see what happens or you know measure it at these times what I found is that maybe half of the patients would meure maybe three or four times a week and they would use it as a way of keeping them on track with lifestyle change it would help motivate them whereas the other half I found would start checking it six times a day if one of them was slightly elevated it would make them anxious it would probably drive up their blood pressure for the rest of the day they'd be phoning and so I thought okay is this good or bad coming back to what you said previously Peter Well it kind of depends right it depends depends on who you are so I like what you're doing as a practice where you have this set protocol you're not really looking at those individual numbers it's like just do you know do this for two weeks and then let us have a look and see what the overall pattern is I think that's useful so given that many people will get their blood pressure at the doctors in this suboptimal way or they're going to pick one up from their local pharmacy where do you see trackers here I know I heard you saying a conversation a little while ago you were checking out a few of these risk trackers you know I hope we get to cgms because I think cgms are one of the most powerful tools I have seen to change behavior in my two decades of practice I I I I don't think I've seen anything as powerful in real time do that but just to finish off on blood pressure a little bit where are you up to with that with your sort of Investigation into this kind of non-invasive um monitoring at home so first of all I just want to reiterate what you've said and I agree completely um I do think people tend to major in the minor and minor in the major a little bit and the the tracking is a tool people tend to get distracted by the tool and they miss the substance the substance is the the Insight from the tool and what you do with it and for some people tracking is a very valuable Insight generating tool and for some people it's also a very valuable uh behavioral tool we as we we'll talk about with CGM um but when I see the debates between the tracking and the anti-tracking community it strikes me as religious political partisan and uninformed yeah and so I I actually try to distance myself from that a little bit um I have a point of view on the benefit of these things um but I'm I I find myself less interested in debating it because I don't find the debates to be full of Merit they tend to be um again they just tend to to you know degrade into sort of unhelpful debates especially online right that's never in my experience you know on Twitter or on Instagram you you especially on Twitter you're very unlikely to you know get to some sort of meaningful place at the end of it where everyone's learned a little bit everyone's their understanding I I know as a fellow podcaster I feel these debates or these kind of things long form podcasting I feel is the best medium to have those conversations because the nuance and context comes out within them whereas online it's just like as you say it deteriorates very very quickly so like you I I just stay out of them and distance and and say what I have to say on this podcast basically yeah yeah and and I've had really interesting discussions with people um about people who who might disagree with me on on various things and and yeah these discussions when you have them properly over the phone or whatever they they tend to be much more productive um so as it pertains to blood pressure um I would have to guess that even the harshest critic of tracking as a general concept would at least have to maintain some interest in continuous blood pressure monitoring yeah because this is something where there are so many limitations of spot checking so even if you get over the limitations we just described which are numerous you still have the limitation of even if you do it perfectly you're only looking at two points in time yeah you don't know what your blood pressure is at night you don't know what your blood pressure is when you're working when you're on a phone call and you're stressed out or when you're making dinner or all these other things and what we really would like to know potentially is what is your average blood pressure over the course of a day and today the only way to really do that is with a 24-hour ambulatory blood pressure monitor what's called an abpm and I've worn one of these before so it's a actual cuff that you wear on your arm that's hooked up to a regular blood pressure machine except that it's smaller and it's set to cycle every 15 minutes and so you wear this thing for a couple of days you take it off when you shower but otherwise you're wearing it 24/7 and it's just cycling like a regular blood pressure cuff every 20 2 hours but the problem is it's so cumbersome that it doesn't really itself to Great use and I for someone like me who actually doesn't mind being tracked I found it so cumbersome that I I quickly got rid of it so there are devices out there now um one of which I've played quite a bit with um that measure blood pressure optically off the back of the wrist and they're calibrated to uh an automated cuff measurement it's too soon for me to say what I think of these devices but but I'm very curious and I'm very hopeful and optimistic that these things pan out because I I I really think that that's a piece of information I would like to know for all of my patients I would really like to know what their average blood pressure is and I I think that would probably be even more important knowing what their average blood glucose is yeah I mean I'm pretty sure we'll solve this problem won't we with technology the way it is whether it's now or in 6 months or 12 months or two years it's it's inconceivable to me that we won't some point have an excellent non-invasive um blood pressure tracker that really gives us that information I guess in in in a way that CGM does right in a way that that gives us information in a very in a way that you can barely know you're wearing one just just going back to blood pressure your target of 120 over 80 as you say is is lower now it's more aggressive than what we were certainly doing five or 10 years ago in medicine um is there a specific trial that made you realize there I think there's quite a few but you know where where yeah I think I think the most recent Sprint trial right where we where we saw that what was then described as aggressive management versus standard management was there a difference and the answer was yeah there really was a difference and would you go even lower so again Lower you're saying with apop you strongly uh believe is better for your risk of uh atherosclerosis um can we say the same thing for blood pressure you know what if it goes to 115 to 110 as long as of course you're not getting Disney Nur or well that's that's the big if right I I mean you know blood pressure is one of those things where symptoms matter a lot on the low end they don't matter on the high end in other words we're not going to wait until people are symptomatic to say your blood pressure is too high but we would certainly back off if if the symptoms are low and that's why you know I'm e I'm you know I'm much slower to turn to pharmacologic interventions on blood pressure than I am on lipids because you don't pay as heavy a price on the lipid side right you you don't need apob this is a big Mis misconception you have plenty of essential cholesterol in your body floating around without apob kids have an apob concentration of 10 to 20 milligrams per deciliter it's nothing and yet kids have no problem with the profound and Rapid period of growth that they go through including in their central nervous system yeah right so think about that all these people who say oh my God you can't lower cholesterol because your brain will starve I mean there's C orally nonsense right the the most aggressive ravenous appetite that the CNS has for growth is during a period of life when you have the lowest level of cholesterol so there is no downside to lowering cholesterol except for the side effects of the medicines that you use to do it and that's we've discussed those and they're important and you need to understand them with blood pressure it's quite different it's not so much the side effect of the medicine it's the side effect which which by the way there are side effects to those medicin but the far more dangerous side effects are the dangerous side effects of hypotension and orthostatic hypotension in particular and so I would much rather use exercise and weight loss and sleep improvements as you know and that includes correcting sleep apnea if it's present as the three first second third line agents to fix hypotension because the body is much better at Auto regulation under that setting than if you have to turn to something pharmacologic and we would really only want to use pharmacologic agents when we have reached the limit of those other three yeah it's such a great point and any practicing physician will know full well the problems with blood pressure medications especially with our elderly populations you know you you put them on a tiny dose and then suddenly you know they get dizzy when they're standing up there's all kinds of things to manage and so I think that's a really nice way of looking at it you know it's your thresholder risk or depend on the downside or the potential downside of that treatment so that makes a lot of sense blood pressure when you look at of course we have a med in person so over Zoom you can't tell how tall I am but I am 6′ 6 and a half I'm nearly 2 m tall right and why that's relevant is when we look at these generic uh figures like blood pressure you want to treat to 120 over 80 mhm and this is of course where Nuance comes into the practice of medicine what if someone like me super tall comes in you know and you could make a case potentially that some people at the extremes may you know I may need a slightly bigger blood pressure because I've got so much more vasculature to you know to pump my blood around my body I I'm not saying I do necessarily I'm just putting it out there as a theoretical how much do you take these things into consideration or when the data is so clear as it is with blood pressure you just go well let's still treat aggressively as long as we're not getting negative symptoms yeah no it's it's a great question and it's a question I've been asked before when it comes to especially tall patients um I guess so the short answer is I don't know yeah I don't I don't think I know the answer um one way that I would think about it is um considering that as tall as you are and you know you're seven eight inches taller than the average person the real question is what is the difference in height between your aortic valve and you know the vasculature of your brain because that's really the part of blood pressure that is working that's the most important profusion part of the equation right that's the part where most worried about is are we getting enough Central profusion in you because the rest of your body is working a little less off gravity in other words that's the part where the heart has to pump Against Gravity um obviously your heart is receiving profusion regardless of your systolic blood pressure that's being perused during diast and everything that's kind of below your neck has the aid of gravity to some extent so so that might be one way to think about it which is even though you're eight inches taller than an average person how much taller are you in an area where your work your heart is working against gravity another way to think about it and I haven't done this analysis um is to look at the blood pressure of say a Giraffe versus another large animal that's not quite as long or doesn't have quite as much distance between ventrical and brain and I'm curious as to I've I remember at one point reading that analysis and I but I've just forgotten the answer yeah really really interesting I love the way you think about this quandry um the the the the sort of looking at giraffes is really interesting not least because you know it has been known for colleagues or friends of mine to call me a giraffe uh so you know I I kind of like I like what you're doing there without that knowledge um but also this is a wider point for me that I've been thinking about particularly I know you have a movement coach I think name is Beth from recollection from the book I and I see a lot of similarities between you and me Peter in terms of approach to Medicine certain personality traits that we may currently have have had are trying to eliminate or reduce but I have my equivalent of I guess what I perceive to be your relationship with Beth I have a lady called Helen Hall in the UK who is just one of the most knowledgeable people about the human body and movement I've ever come across and you know there's all kinds of things we do together to optimize the efficiency of my movements and you know my muscle sequencing and efficiency and all kinds of things but let's take running for an example A lot of people who talk about running will talk about the Cadence should be around 180 uh you know foot fors per minute something like that that should be your Cadence and you know I'd read this stuff and I'd absorb it and I'd try and implement it I'd get metronomes I'd try and stick to 180 and be like this is kind of I'm struggling here this doesn't feel like I think it should feel through my work with hel and I've been working with there for about three years now she say wrong I just I just don't think that's the right thing for you you've got super long legs it it's just a a simple example of where generic advice can start to become problematic if we don't put a bit of context in So currently my Cadence which is beautiful for me is about 162 and she's watched me run she's measured me which is quite a lot different from 180 but then I'm also quite a lot different from the average Runner so that's the kind of context behind my question no I I I actually it's funny to bring that example up I was the same way in swimming I mean there's really a clear sense of what your Cadence should be in swimming in terms of arm turnover and um my Cadence is significantly slower than anybody else's that I've ever swam with I've never swam alongside people I've never swam alongside a person who has a lower Cadence so um for whatever reason my style of swimming was such that it was better for me to turn my arms over less and just pull harder and glide try to Glide further um and anytime I would try to pick up that Cadence um it would usually backfire so there was no Rhyme or Reason for it and it frustrated me to no end until I finally just accepted it and said this is my Cadence um there one other point I want to make going back to your particular example which is you know this is where I think we can be more judicious in our use of other biomarkers to help us understand the tradeoffs so for us one of the most important biomarkers is cystatin C which we we tend to rely exclusively on that and not on creatinin when it comes to understanding kidney function we we tend to ignore creatinin entirely um because it is so influenced by muscle mass exercise status things like that that it always seems to I mean I would say without being factious 80% of the time I think it's under or overestimating kidney function to the point of being unhelpful so we're looking at cattin C which I think the literature makes very clear is a far superior biomarker for kidney function and of course then we look at you know once a year so we'll look at that every time we look at a person's labs and then once a year we'll also look for urinary protein and things of that nature and so that might be another thing that you can be tring if you're saying look I'm going to go off the beaten path a little bit by measuring blood pressure and accepting a slightly higher level is saying well is my cyat and C very very you know is is it low enough that I can say my my estimated GFR based on Cat and C is still very high and if you're seeing any compromise there the first place we look of course is at blood pressure so the starting point is exercise is the number one factor for our longevity recently you were asked I think it was in the Q&A you guys published on your show that a chap who's playing tennis twice a week and basketball twice a week um is that okay and I think your answer was it's probably not optimal to the person on the street I believe if they heard that someone was playing tennis twice a week and basketball twice a week they would be thinking wow that guy's crushing it so I wonder if that's a good way of explaining your model for exercise and why we need this broad approach to movement so maybe I'll explain what the centenarian de cathlon is and then I'll come back and your your question's an interesting one so the centenarian decathlon is a model that we use to Anchor the marginal decade so again the marginal decade last decade of your life so what we want our patients to be able to do is identify again in great specificity phys physically what they want to be able to do and the physical manifestation of your marginal decade we just describe as your centenarian to cathlon so you might have lots of goals in that marginal decade they might you know you should hopefully have some cognitive goals uh hopefully you have some emotional goals goals Vis A V relationships um but when it comes to the physical goals we we want you to be very specific and we start by saying look we we we have a menu of options and we want you to at least be able to identify 10 that you want to be able to do and again these are very very specific um and I think there are some of these that many people would have on their list and there are others that are unique to individuals so there are some that are on my list that most people wouldn't care for like what would you say uh I'm sure most people wouldn't care that you know I want to be able to pull a 50 PB bow back I love archery so you know and currently I draw like a 75 pound bow but I want to be able to still draw a 50 pound compound bow um I still want to be able to drive a race car to within about 5% of how fast I can drive it today you know Paul Newman up until a few months before his death was still driving at this you know almost at his best times so you know those are some really kind of weird esoteric goals for me um but then I also have much more generic goals that I think make sense like I still would want to be able to walk up five flights of stairs uninterrupted I want to be able to walk down five flights of stairs those are diff those are require very different types of strength and um um Integrity of of the musculature um I want to be able to get up off the floor uh I want to be able to sit on the floor for 20 minutes and I want to be able to get up on my own power M again how often do you see somebody in their 80s that can do that it's very very unusual um you know I want to be able to pick a child up out of a crib I want to be able to pick a child up off the floor so there are many of these other goals that I have now um how does one go about doing that well again I think if you are listening to this scratching your head a bit thinking those sound really really easy how can those be goals you probably haven't spent enough time around people in their 80s or 90s those are staggering physical Feats so let's think about what decathletes do a decathlete is an athlete who performs 10 different activities and the decathlete is not the best at any one of those activities right like when it comes to the 110 meter hurdles or the 200 you know yard meter dash you know they're not the fastest M but no one is faster at doing all 10 of the things that they do which Encompass both the track and field events and um they're generally regarded as the best athlete in the Olympics uh and they train as a generalist but with great specificity yeah and so I think we have to apply the exact same model to ourselves as we prepare for those events we have to be great generalists so we have to have high peak cardiorespiratory Fitness wide aerobic base high levels of strength great amount of stability all of these things and we also you know have to be able to train very specifically to achieve those things so now let's go back to the question that you asked at the outset so is playing tennis twice a week and basketball twice a week sufficient to prepare you to be the most robust 85-year-old and I said believe it or not I don't think the answer is yes yeah because as wonderful as those sports are they don't cover all the bases that I just described they're not building a very wide aerobic base nor are they building a very high cardiorespiratory Peak those are both very intermittent Sports start stop start stop um they interval training and that's great interval training is a very efficient way if you had no other time to get bits of both the aerobic base the anerobic peak but it it's no substitute for having a really wide base and a really high peak also they're not doing a lot for your strength directly they're not doing a lot for your stability in fact they're challenging your stability so if a person says I love doing those things I say great keep doing them if a person says I want to be able to do those things in my age 0s I say great I think that's doable but you will need to train to ensure that you have the strength stability and the endurance to do those things well yeah it it's such a wonderful framework to look at aging and I I I like this idea that you specifically get your patients to write down what are 10 things I want to be able to do in my marginal decades now I've heard you say once that a couple people will say I want to be helis skiing does that person in their 40s that say Really Want A hel ski when they're 95 or is hel skiing a way of saying I want to be independent and being able to enjoy the mountains and nature whether they do or not the point is by you knowing that by them articulating it it means they can develop a specific program with you and your team to help them meet that yeah completely and the other thing is these things can be malleable I mean there's if you'd asked me this question 10 years ago I don't know that there there might not be many things that overlapped 10 years ago because 10 years ago I probably would have taken for granted so many things that I don't understand today and wouldn't they wouldn't have even made the list and there would have been other activities in the list that aren't as high a priority to me today so for example now in my marginal decade I would be happy to swim you know half a mile I think that's one of my things is to be able to swim half a mile in 20 minutes um how have you where have you got that from well you know swimming used to be very important to me uh so so you know again if you'd asked me this a decade ago I probably would have wanted to have swam 10 miles and I would have really over indexed swimming and being able to swim really really long distances whereas now swimming is much less important to me so it's mostly just about being able to still enjoy the water and you know if it's swimming half a mile now that would be sufficient it's you know can I tread water you know one of the things I have now is can I get out of the pool on my own like again without a ladder could I push myself up on a pool deck and get out of a pool so it's it's just less focused on the time in the water but you're you're right um if you if you if you go after hella skiing and when we have patients that say things like that I mean I I'm not going to discourage somebody from that but I'm also going to say like that's going to require an astronomical amount of strength um and you're going to have to be a lot stronger in five years than you are now to appropriately catch the Glide rate down to where you're going to be at that point in time and by the way if you miss if you fall short you're still going to be able to do a lot of great things yeah but let let's go for it yeah no I I I love the approach you bring a specificity to something that is other otherwise vague I just want to be well while I'm older what does well mean like well for what yeah that that's the thing that that I we really try to get people to understand is no one no athlete and you have to think of yourself as an athlete here no athlete has ever achieved anything great without specificity I mean like pick any athlete doing anything today that's exceptional do you think they're just out there willy-nilly going me you think jokovic is like yeah it would be great to win Wimbledon I'll just play tennis a bit each week I'll just play a little bit of tennis each week I mean no chance yeah I mean no chance the the and again like we live in a world where Sports Science has made it really clear as to what it takes to achieve these physical things so so there's really there shouldn't be any difference when you're thinking about the activities you want to be able to do in the final years of your life there's a real irony about that Sport Science because on if I think about Humanity as a whole on one hand we're now seeing just incredible Feats that we've never seen before let's say Kip chogi running a marathon in under two hours something that was deemed physiologically impossible maybe 10 15 years ago by by certain people it's not possible the human body will what self- implode or whatever right so he's shown that that's possible we're seeing World Records left right and Center going down we're seeing you know Premier League footballers playing into their 40s you know things that we didn't think was possible yet at the same time so the elite it seems are getting the benefits of all the latest sports science and are you know pushing new limits what humans can do yet it feels like the Baseline of what the population is able to do is going down and I don't know if you saw this there was a a study recently I think it was 25 million kids in 28 different countries they basically observe that I think it's compared to maybe 30 years ago the average speed it takes a child and this is between the ages seven and 17 the average speed it takes to do a mile has gone up slower they're 90 SL they're 90 seconds slower so there's a there's a certain irony there isn't there that's a great point two things you said P which I think are really important number one the point you made about if you think you're going to be okay you probably haven't spent much time with people in their 70s ‘ 80s or 90s or if you're going to be okay without doing anything and unfortunately in my own life there's been a um a stark realization this year um I won't go into all the details but my mom who lives 5 minutes away from me Christmas Day evening she'd had a fall she got admitted to hospital she was in for 3 weeks there wasn't enough s to take it out of bed I'd go in and do my own rehab I know how quickly one can decondition and unfortunately since Mom came home 3 weeks after being in hospital she has not been the same she has not recovered to anywhere near her Baseline so first point I wanted to address was um if you haven't seen it you may not take it as seriously as it needs to be taken and then the other point related to that and and I kept this page open in your book it's in the chapter on Training 101 but the graph that you have pulled from the um Jason Clifford and Brigham Young University I spent so much time looking at that graph I think everyone should look at it this is figure 11 yeah figure 11 yeah this is the V2 Max decline it it is utterly remarkable the central point I get from you is that decline is inevitable in your physicality it's going to happen you've said before that we we understand at what rate it is likely to happen and and I think it's genius this way that you go if you want to do that in your 90s or your 80s whatever that point is you have to account for the decline and therefore you have to be able to do some specific things in your 40s now many people who listen to this show pizza do park run community events every Saturday where you run or walk 5K MH right so I don't know if you're up for a little um experiment here but this graph basically has uh well maybe would you want to explain the graph because you're probably better at doing it than me sure yeah so the the graph uh it shows I could probably do it from memory but it it shows three three lines so these lines are placed on uh against an X and Y axis so the x- axis is your age and it's uh obvious ly increasing to the right and the Y AIS shows the V2 Max now I can't remember how much we discussed V2 Max on the first we didn't so let me explain this first so um V2 Max stands for maximum ventilation of oxygen so what is ventilation uh ventilation rate or minute ventilation rate of oxygen it it means how much oxygen you're using at any point in time so ventilation rate is defined in liters per minute and and um you and I sitting here right now having this discussion are probably at 3.4 lers per minute uh may maybe 0.5 lers per minute because we're a little animated in how we're speaking right so we're at 500 CC per minute of oxygen consumption if we were to stand up and walk around this room that would maybe increase to 1 liter per minute if we were to go outside there and jog back and forth you know that would increase to 2 and 1/2 L per minute and eventually if we kept forcing ourselves to exercise at ever increasing pace and demand we would reach a maximum yeah and that can be tested for in a laboratory so it's done either on a bicycle or on a treadmill stationary because you have to have a mask put over your face and the mask is what is able to measure the amount of oxygen you're consuming and this is one of the more important tests that's done by Elite endurance athletes and so if you talk about the most elite endurance athletes they're typically going to be cyclists CrossCountry skiers Runners and so whether it's Kip chogi or Teddy pogacha you know I mean these people have astronomical V2 Maxes yeah so the higher it is the fitter you are this is your Peak aerobic uh uh capacity it's normalized by weight so ultimately the numbers that you're used to seeing are reported as you know a number say 50 uh and it's converted into milliliters so 50 milliliters per minute per kilogram okay so the higher that number the fitter you are and so you know um we have tables that tell us and I think I put one of those in here that tell you by sex and by age where you rank by percentile now this graph is showing something different it's showing people in the top I think 5% yeah the the middle of the pack so the median or the 50th percentile and the bottom 5% and it's showing over time how those three lines decline they all decline they all Decline and in fact the the rate of decline is actually steeper for the fittest people because they're starting at the highest point but even though it's steeper they still have they always remain higher they remain higher that's right so you always want to be on the top line what this graph also does that I find interesting and the reason included it in the in the book is it shows various activity levels and what they correspond to in terms of a given V2 Max so that you can observe when various people cross over so at this point I've lost my ability to memorize it so I'll just kind of turn to the graph so for example briskly climbing stairs requires a V2 Max of approximately 32 ml per kilog per minute it doesn't matter your age right if you want to go bristly upstairs that's right whether you're at 30 or 90 you require you need to be at about 32 milliliters of oxygen per kilogram of body weight per minute okay now here's what's interesting people in the 50th percentile of the population at the age of 25 have a V2 Max of about 44 so they can do that pretty easily by the time they reach 50 they've descended to that level so a person who is my age who's 50 at the middle of the population's fitness level is just at the point where they're going to lose the ability to briskly climb a flight of stairs and it's only going to go down from there now interestingly someone in the bottom 5% even at the age of 25 is below that level wow okay now let's look at someone in the top 5% someone in the top 5% who by the way at the age of 25 is at about 62 in terms of their V2 in terms of their V2 Max they don't hit that level of being right at their threshold until they're 75 so one of the things about this graph that I find interesting is it stops at 75 so one of the reasons we show this graph to our patients is to say oh and by the way the reason we hold you to a higher standard than this graph we hold our patients to a standard of being it's aspirational but this is what we want everyone to be at we want everyone to be at the top 5% for someone 10 to 20 years younger and the reason for that is we want you to actually be able to thrive into your final decade of life and you have said pizza before there is no reason that most people cannot be in the top 25 % absolutely not there it's there is simply I mean you would have to have a mitochondrial disease to not be able to reach 25% of your age so this is really empowering I think for people that no matter how old you are of course the earlier the better you want to give yourself buffer room so let me just summarize to make sure I've got it right make sure everyone's following along that essentially your V2 Max is a super important metric it is going to get worse as you AG in a relatively predictable fashion therefore if you want to be doing something like briskly walking upstairs in your 80s we know what V2 mats you need in your 80s and therefore we can say what V2 mats you need today and it's such a logical and beautifully simple way of looking at it and it makes it very very tangible the reason I brought up parkour and pizza is because one of the things it talks about in this graph is jog 6 mph on flat ground right so 6 mph is roughly 10 minute mile Pace yep right a 5k so a park run for anyone who does park run I appreciate some people walk but that is you know roughly a half an hour park run I think a lot of people I know a lot of people my age or 10 years older who AR in great shape but they can do a 30 minute 5K right so what's really interesting to me is that I mean it's just it's brutal this graph it's utterly brutal right if you are about 37 years old right give will take a year I haven't got exact lines going down so if you're 37 years old and you can do a park run in half an hour like by the time you are 75 you can barely walk up a very gentle Hill at 3 miles hour yeah if if at 37 your limit is just being able to run that 30 minute park run you at 75 you're going to have a very difficult time getting around so at so in other words at 37 you need to be hammering through that park run you need to be running it in 21 or 22 minutes if you want to make sure that when you're 85 you have no physical impediment I mean the way I describe it to to patients is I I'm not I'm not so deluded to think that at 80 I'm going to be doing what I am today but what I want to know that I can do when I'm 80 is take a train through Europe and take my own luggage with me and I pay attention to what that means now I pay attention to how quickly I sometimes need to move through a train station with my luggage and even now I know like like you have to hustle sometimes so like now it's not the limit of my ability today but I if I'm banking on that being the limit of my ability in when I'm 80 I know what level of Fitness I have to have when I'm 50 yeah and it's way higher it's way higher the decline is inevitable so you need to give yourself buffer room and again just to be clear like I get not everyone's a runner right so it's not that you have to do a 30 minute 5K or be you know some equivalent version whether it's yeah I'm not I'm not a runner either so but it can be other things so I do most of my cardio training on a bike or on a treadmill or and if on a treadmill I do it on a steep incline or on a stair climber yeah um and I've just decided like and I still go back and forth sometimes I want to get back into running cuz I used to be a runner but I'm like you know what I'm not going to do it I'm Gonna Save my joints I'm gonna let it go but there are lots of things that I still need to be able to do on my feet I love being outdoors I so I rock a lot and that's a great way for me to add the conditioning element and and for people who've never heard that term rck would you mind explaining it yeah so it's it's walking uh with a very heavy weighted backpack so I I I walk all over our neighborhood which because I live in Austin it's all Hills so it's great up and down very steep hills with a weighted backpack and depending you know sometimes I will go with 60 lbs which is normally what I do and there are other days when I really want to push it I'll do 100 pounds and um and and that you know I'm walking but it's still the most taxing thing you can imagine when you're carrying that much weight to walk you know up a hill that's 15% grade with more than half your body weight on your back so so there you don't have to be Runner I think is the point to test this system and the other thing that is important to understand is it does all at the end of the day come down to what you can do on your feet so being able to walk on an uneven surface being able to walk up a hill um those will become the rate limiting steps as you age I want to go back to something you said earlier and I'm sorry to hear this news about your mom but it actually is a sad illustration of a very important point now I write in the book about the fact that the mortality from a fall if you're over the age of 65 and break your hip or femur is as high as 30% at one year and most people myself included when I first learned of this literature because I did a whole AMA on this topic and initially when the analysts because I have a team of analysts that helps me with everything initially when they were pulling this literature I was like guys come on this is nonsense use your logic here there's no chance the mortality can be that high and they kept showing me paper after paper after paper and this is often the case the analyst just keeps showing me data and I'm not willing to believe it and I'm like guys come on you're being stupid here like yeah I love that you should logic guys it's like wait a minute yeah yeah and it's like oh they're actually right you know so you know it's like I would say a very conservative bracket is 15 to 30% of people once they reach the age of 65 if they fall and break a femur or hip they're not going to be alive in a year but here's a stat that I didn't include in the book and I wish I did because it's just as important of the 70 to 85% who are not dead in a year 50% of them will have a complete reduction in level of function by one measure of unit so for example if they used to walk freely they will now require a cane for the rest of their life if they used to require a cane they will require a walker if they used to require a walker they will be in a wheelchair so in other words there there's a huge cost to this and um there's actually another graph in there that I think is very sobering which shows the mortality associated with accidental death by decade and um a appropriately so we in the US are very fixated on um accidental death due to opioid um because this last year was the first year that that number of deaths eclipsed 100,000 in the US it's a staggering number I believe it it's 106,000 people died in the US last year due to opioid poisoning but at a population adjusted basis that's nothing compared to what Falls do to people over 75 that's the graph I have in there which shows deaths normalized per population basis and all other forms of accidental deaths of which the other two big ones are overdose and autod death they're completely dwarfed by deaths associated with falling so yes the point here is most people in their 40s in their 50s I mean it just wouldn't even occur to us that you could fall let alone that a fall could be the end of your life either e in that moment or more much more commonly in the coming year yeah it's it's incredibly sobering hearing that of course I've seen that firsthand with my mom a demonstration of that this idea that well it it fits what we've just been talking about even though we may be talking about strength per se now or a mixture of strength and stability I guess the principle of the V2 mats declining it's the same kind of thing right we're going to decline and and it is it's the it's strength and its stability and it's um you know the the point we're going to decline need the buffer room so that if we do fall and break our hip when we're 65 we don't want to be in that 30% bucket we don't want to be in the other 50% bucket of the ones who yeah are not dead right we want to be in the other bucket where we are I don't know what percentage that is where you get back to your preall Baseline that's what we want and to do that we need to build a buffer right so you have these four pillars of exercise or movement when it comes to being that generalist who's able to do the things that they want to do in their marginal decades so you have strength you have Zone 2 cardio you have V2 Max and you have stability and I I really want to make sure we make this as practical as possible for people right but I wonder if it's worth just giving the broad Overview at the moment of these four pillars and I don't know if we can say this or not but what percentage of time perhaps no feelings about that we should Advocate to each one yeah so so so you you've got it right those are the four pillars I will say that we have the most data the most Clarity around two of them strength and V2 Max um so the data for strength and V2 Max are undeniable meaning we just have so much epidemiology that is so uniform in its direction so strong in its signal um that you and I go through this at Great length in the book because I want the reader to understand the difference between good epidemiology according to the criteria of Austin Bradford Hill and weak epidemiology for example what we see in nutrition where the epidemiology has a very difficult time parsing signal from noise uh but in exercise that's not the case and I go through all of the criteria why um so when the epidemiology says having a very high V2 Max leads to a longer life I mean it's Crystal Clear yeah um and by the way we haven't mentioned that so it's worth mentioning that so everything we've talked about so far Visa V2 Max has been in the context of quality of life which for most people matters more than length of life but it should be noted that a high VO2 max is associated with a lower all cause mortality to a greater extent than any other health metric including not smoking not having high blood pressure not having coronary artery disease not having endstage adrenal disease none of those compare to the harm that they bring more than being unfit does so the association the the hazard ratio for being in the top 2% of V2 Max compared to the bottom 25% is a hazard ratio of over five it's just it's a it's a staggering yeah it's almost as staggering when you consider having high strength high strength to low strength is almost as potent it's a hazard ratio of over three and for people who don't know Hazard ratio Peter explained it in depth in our first conversation yeah yeah so so okay so let's talk about these things um why is strength so important why is stability so important and stability by the way there's a whole chapter on it because it is the most foreign concept of those four so it warranted the exercise component or section of this book is three chapters but stability is by itself one of them stability basically is the capacity to transmit force from the body to the outside world and vice versa stab and uh without without injury would be the easiest way to explain that so every time you're taking a step you're transmitting a force to the ground that's what that's what propels you forward but a force is being transmitted in the equal and opposite direction back to you so what prevents your knee and hip and back from hurting it's stability what allows you to do that efficiently is stability so typically when an elderly person falls it's due to a lack of strength and stability stability is for example you know what allows the the foot to maintain balance uh if you think about it and watch yourself in the mirror if you're doing an exercise standing on one leg let's say you're doing uh a single leg RDL or something like that you'll notice that that foot is is twitching like crazy to to to try to preserve balance an RDL Romanian death deadli for anyone who's not familiar with that yeah but but look stand in front of a mirror and stand on one leg and watch your foot Watch what it needs to do and we think of that as balance but balance is kind of like the readout state for stability yeah um most people probably have heard of different types of muscle fibers fast fast twitch muscle fibers and slow twitch muscle fibers well the fast twitch muscle fibers the type two muscle fibers are the muscle fibers that give us power the slow twitch muscle fibers are the ones and I'm oversimplifying a little bit but they're the ones that kind of give us more endurance so you can have strength in both of these fibers but the explosive power comes in the type two muscle fiber well that is the Hallmark of Aging is the atrophy of that type two muscle fiber so hold on pie just so when we hear about fast twitch some of us will go to yeah if I want to be a 100 meter Sprinter that's what I need what's the relevance of that to when I'm 880 years old because when you're 80 years old if you lose your footing slightly and you let's just say you're you're stepping off a curb and you lose your footing you need to be able to react with enormous force and that's those fast twitch the term fast twitch and slow twitch is unfortunately a little bit misleading while it is completely true that fast twitch fibers twitch faster it really means and the real reason we use the terminology is they are fast to fatigue because they are much more powerful so a better way to think about it is you have high power fast fatiguing fibers and you have lower power very slow to fatigue fibers and unfortunately as we age we lose the former and so much of the injury we see in people as they age is the direct result of the atrophy of that powerful fast to fatigue MUSC muscle fiber now if you train it you can maintain it now you'll never M no 80-year-old is going to walk around with the volume of fast twitch muscle fibers that a fit 30-year-old has that's not going to happen but a well-trained 80 yearold can still have the fast twitch muscle fibers of a 60-year-old and that's what we want to have we want to know that we still maintain some power in those muscle fibers and that's why for example lifting heavy weights is essential for everyone at every age be it man or woman so again one of the big misconceptions is women don't need to lift weights you know that's completely incorrect one of the misconceptions is you know as you get older you shouldn't be lifting weights I mean this is a complete misconception so strength training is imperative for people um as they age and um not only does it have an enormous impact on bone mineral density uh but it has this enormous impact on these type two muscle fibers we were talking about fast twitch and sprinters I just want to clarify when you're lifting weights does it need to be done with speed in order to really help that fast twitch fiber or just simply lifting a heavy weight slowly also count as a stimulus for that particular it still does it doesn't have to be lifted quickly so it really comes down to the weight so you have to lift a heavy enough weight that the type two muscle fiber gets recruited and if the weight isn't heavy enough the muscle will the muscle will simply recruit the slow twitch fibers to do the work yeah if we just zoom out for a moment and think about a lot of the centenarians that we see being interviewed and of course that's not a scientific study this is just observations of humans in blue zones or wherever it might be what strikes me as very interesting is that very few of them were trying to work on their longevity from what I can tell right it doesn't mean we shouldn't be it also is pretty obvious that most of those people are living in environments whereby a lot of the things that you write about were being automatically covered let's say I don't know a farmer in Sardinia still still hurting goats in his 80s right well it's kind of going up hills a lot walking V2 Max probably lifting things around I I I just I think it's always good to zoom out and go okay these guys weren't measuring every metric they weren't looking at these decline graphs I feel and I wonder what you feel about this is that because of the way many of us now live we kind of need these Frameworks to help us achieve what these guys are doing naturally yeah would you see it different way no I see it exactly that way do you remember uh in in like the original Spider-Man Story You've Got Peter Parker when he you know when he when his Uncle Ben gets shot yeah and um you know right before that his uncle says to him something which is you know Peter with great power comes great responsibility and I kind of always have that in the back of my mind when I think about modernity um do I like the fact that it's 2023 right now uh or is there any reason I'd want to go back to 1923 or 1823 if you gave me a time machine the answer is zero chance there's no chance I'd want to go back to 1923 or 1823 or 1723 so in other words I fully buy the beauty of the modern world we live in it's not perfect but it's better in the world 100 years ago 200 years ago and 300 years ago but it comes at a cost like everything and we have to be very mindful of that cost and by the way I think that exercise and nutrition are probably the two greatest examples of where we pay that price so you know we spent hundreds of millions of years evolving depending on which form of ours you're consider considering but even if you consider just Homo sapiens right like just think of the last hundreds of thousands of years of evolution what really gave us our superpower to Leap Frog ahead of all these other species was our brain MH and what enabled us to have a brain that was so energy demanding was the capacity to store energy yeah so in some ways the human superpower from an energetic standpoint is the capacity for energy storage we are very efficient at energy storage that served us incredibly well until relatively recently when energy became so abundant energy of course in the form of food that superpower became a detriment yeah and now most people certainly in the developed world are overnourished and we're on the wrong side of the energetic curve yeah does that mean that we should all aspire to be hunter gatherers again where we don't know where our next meal is going to come from no it just means we have to understand that with this great privilege came a responsibility the same is true with movement our ancestors didn't deliberately exercise if they saw that there were things like gyms and treadmills they wouldn't fathom what we were doing but all of this is a construct we've had to create yeah to compensate for the fact that the modern world has taken the need for all movement out of our lives so we have to go above and beyond so so maybe if if you know if you're listening to this and you're a person who doesn't like exercising that's fine but just understand that there's a huge responsibility that comes with living in the modern world to yourself yeah and even though you know your ancestors five generations back wouldn't exercise um they didn't need to because of what they were doing in the book you made the case that exercise May well be the most potent longevity intervention that exists number one do you still stand by that since you pressed print and the manuscript went off to the to the Publishers uh and if so why do you put that right at the top uh the answer to the first question is very simple yes I I certainly do um and the answer to the second question is also quite simple which is it really is not a matter of opinion it is simply a matter of the data the data make it abundantly clear I kind of alluded to this a moment ago but um maybe for the sake of the audience we can explain what a hazard ratio is right so a hazard ratio is a number that um communicates the relative risk of one condition relative to another so so uh for example the hazard ratio associated with all cause mortality for a smoker versus a non-smoker is about 1.4 and so statistically what that means is a smoker is about 40% more likely to die in any given year than a nonsmoker all other things being equal that's what the 1.4 means and you know if we were to look at something some intervention I'm making this up but you know drinking a certain type of tea if that had a hazard ratio of 0.91 we would say that that intervention is associated with a 9% relative reduction in Risk if the hazard ratio is one it means there's no difference okay so that's that's the math on Hazard ratios so when you look at the hazard ratios associated with all cause mortality and of course all CA mortality is the gold standard of thinking about lifespan we're going to talk about health in a moment but we'll just bracket this on lifespan um let's consider the the the known things that Rob people of lifespan type two diabetes high blood pressure coronary artery disease smoking endstage renal disease those would be the big ones what are the hazard ratios associated with each of those conditions well at one end of the spectrum you see hypertension has a hazard ratio of about 1.2 it's about a 20% increase in all cause mortality meaning you're 20% more likely in any year to die than someone who's otherwise equal without hypertension smoking as I said is about 1.4 1.41 uh coronary artery disease about 1.3 type 2 diabetes about the same endstage renal disease about 2.75 somewhere between you know 1.75 and 2.75 so anywhere from a 75 to 175% increase but now when you do the same analysis based on different metrics of of cardiorespiratory Fitness strength and muscle mass the numbers are simply bigger and they're bigger by a lot so for example when you look at comparing the V2 Max of somebody in the bottom 25% of the population for their age and sex so meaning someone in the bottom quarter of their age and sex in terms of maximal oxygen uptake which is a test that we can readily do on people it's a measure of peak aerobic capacity and you compare that to someone in the top 2% of the same age and sex the hazard ratio is five slightly over five meaning it's a 400% difference in all cause mortality in fact if you just go from being in the bottom 25th percentile to being slightly above average from the 50th to 75th percentile the hazard ratio difference is 2.75 meaning it's even more significant than having endstage renal disease I could go through this analysis all day long and I could do the same thing for muscle mass and I can do the same thing for strength but across the board the difference in all cause mortality is significantly wider when it comes to measures of strength and fitness than it is for any disease condition we know and so the coral are of all of this is by definition whatever it is you have to do to have that higher V2 Max greater muscle mass and greater strength must be hands down the the most potent thing we have at our disposal to live longer and of course the only way one can have those things is through the right type of exercise yeah I really appreciate how you broke that down Peter very very clear I definitely want to dive in here but let's just clear up a couple of things before we do um you mentioned Health span and lifespan I wonder if you could explain exactly what you mean by them and then I think it would be useful to talk about your for Horsemen because I think it's such a beautiful concept for people to get their heads around the kind of core philosophy behind your approach I think it would be quite useful to to start here if that's okay sure um so the word longevity is kind of a shorthand word that people sort of loosely have an idea what it means but it's also a word that's been largely bastardized by uh a sort of you know Shady collection of people who pre on the fears of you know people who are afraid of one of the most frightening things we experience which is the fear of dying so um I generally don't love the word longevity despite the fact that it's part of the subtitle of the book but I use it because again it it has such an obvious shorthand for what we're talking about but if we want to be more technical what we're really talking about with longevity is two vectors one is the lifespan vector and one is the healthspan vector now the lifespan Vector is the uh more you know call it objective easier to understand binary digital whatever word you want to use it's on or off you are either alive or you are dead and there are certainly going to be some gray areas around brain death but for the most part people have a clear understanding of what it means to be respiring versus not and so you know your lifespan ends when you die and at least one part of longevity is on some level extending lifespan but I think unfortunately there's kind of a you know like a Silicon Valley ethos around extending lifespan to you know magical numbers we're going to everybody's going to live to 150 or 200 and um you know the reality of it is I just think that that's not only far-fetched um but but I don't think it's really what most people are interested in I think what most people are interested in even if they can't articulate it is the other side of the equation which is the health span side which is the quality of life piece I alluded to this earlier this is the piece that medicine 2.0 is failing in dramatically so not only is medicine 2.0 failing to add much years to lifespan Beyond what's already been done but we're doing so at the great expense of Health span and health span is harder to explain because it's more nuanced first of all I think there are three components to it but it's also analog it's not binary it's not on or off it's relative and it declines in slow perceptible ways and at times it declines very quickly for example a person that suffers a devastating injury would experience a dramatic reduction in one of the three areas of Health span which is the physical component right the the body the exoskeleton there's also a cognitive piece and an emotional piece and then further complicating all of this is that two of those three are heavily aged dependent the physical and the cognitive while the third the emotional bucket is actually not age dependent very much at all in fact sometimes we get wiser with age to enhance our emotional health I mean we we definitely get to emotional health but I really appreciate you outlining that how does these four horsemen fit into this conversation around healthspan versus lifespan so when you want to think about the lifespan side of this equation it seems only logical that one must have a great understanding of what the impediments are to lifespan in other words what takes our life away and for a nonsmoker this can be pretty easily distilled into the big four and the big four are the diseases of atherosclerosis so cardiovascular and cerebrovascular disease Far and Away number one followed by cancer of course as you and your audience know cancer is not just one disease you know cancer of the breast is different from cancer of the colon but collectively all of cancer number three is neurodegenerative disease and related dementias so neurodegenerative disease includes Alzheimer's disease Louis body dementia Parkinson's disease and it also includes other types of dementia such as vascular dementia fronto temporal lob Dimension things like that nature and then the fourth Horseman is not so much on the list because of the number of lives that it directly takes but because of the number of lives that it indirectly takes and that's less a disease and more of a spectrum the Spectrum ranging from insulin resistance and naff or non-alcoholic fatty liver disease all the way to type two diabetes it's basically what we think of as the metabolic diseases which again in terms of how often those diseases show up on the death certificate the approximate cause of death is not that large you know we're talking about in the United States maybe a 100,000 or so I would imagine in the UK slightly less but it's how those things amplify the risk of the other three Horsemen by typically about twofold so um what we really want to be careful of is understanding that when you have type 2 diabetes non-alcoholic fatty liver disease insulin resistance your risk of cancer neurodegenerative disease and heart disease goes up significantly and so by understanding everything we can about the four horsemen we have a chance to delay their onset and that's really the objective here I don't think we are in a situation barring science fiction to completely eliminate the horsemen certainly some of these diseases seem somewhat inevitable to our species um cancer for example at the end of the day is ultimately a tug OFW between acquired genetic mutations that alter cellular properties and the ability of our immune system to detect them and evade them um but we can certainly delay these and we have great proof already that that happens and the proof exists in the longlived people the so-called centenarians people who live already to the age of 100 or more and we know from studying these people that their superpower is not living longer with the four horsemen it's living longer without the four horsemen once they come down with the same diseases as the rest of us the time it takes for them to die is about the same it's that they get the diseases about two decades later than everybody else yeah and that's what we have to figure out yeah super interesting that's really quite something for us to reflect refs on that these super centenarians once they get the same problems that we get the time to death is pretty similar it's just trying to delay that so coming back to the problems with the medical system the way it's set up the way we're trained the way many of us are still practicing we get involved very very late you know we diagnose type 2 diabetes at some you know theoretical uh point that we have defined um for many years I've been teaching doctors in the UK saying listen guys we're we're still reporting in hba1c if we we have slightly different cutoffs to you guys so we have 6.5 yes as the cut off for type 2 diabetes but we call pre-diabetes here uh from 5.7 where I believe you guys start at six but nonetheless you know a lot of the time we're reporting these suboptimal blood sugar levels as normal and and the way it works in the NHS typically here the naal Health Service is what will often happen is that you will get your bloods drawn and you will often be told if you don't hear from us everything is okay now first of all that is unsatisfactory on a number of levels a it's such a big juggernaut with a system things go wrong things get missed all the time so I would always say to my patients phone up make sure you've got your result make sure someone has said something about that result just don't rely on the fact that nothing's come in the post so you're okay but the wider point is is that even many doctors are not getting involved with their patient or not taking preemptive action until it's quite far Advan you know type 2 diabetes Alzheimer's you know dementia for example you know Dale breson will say that that condition maybe starts in the brain maybe 30 years before you actually get a diagnosis for example and so from your perspective Peter I know you have quite a bespoke and very targeted practice you know what are the things that we should be looking out for what are the things that we can all start looking at in ourselves to make sure that we're not waiting until these diseases have set in and we've got Advanced endstage disease you know what are what are these key things that maybe we're walking around with but we're not aware of them well it certainly varies by disease but let's take the clearest uh example of where prevention is unmistakably able to get us to the point where we would be far more likely to die with a disease rather than from it and that's the ultimate goal right so you know I'm sure you've shared this with many of your male patients I mean any man who lives long enough will die with prostate cancer but some will die from it right but most men do not die from it they die with it and so the most broad example of that from a disease perspective is atherosclerosis um everybody has it to some extent the goal is to not die as a result of it not to die of a major adverse cardiac event a heart attack a stroke so what would be required to delay the onset of atherosclerosis something that I argue is probably somewhat inevitable to our species um well again this is where understanding your opponent matters now heart disease it turns out atherosclerosis we have a great understanding of its pathogenesis and we know that while genes play a significant role those genes play a significant role often through the modification of the following Pathways lipid related Pathways blood pressure related Pathways endothelial dysfunction related Pathways so what are the big risks for heart disease smoking high blood pressure elevated apob and metabolic disorders so the most extreme example being type two diabetes but again any disregulation of glucose and insulin is going to be amplifying the risk of type two diabetes pardon me of cardiovascular disease so how can we take that information and act on it so that we delay its onset by two decades well this comes down to how you view the world through the lens of prevention so I can't speak to how it's done in the UK but I can tell you that in the United States we tend to view things through a Time Horizon of about 5 to 10 years so we use risk calculators the risk calculators incorporate information such as your family history whether you smoke or not what your lipids look like your blood pressure things of that nature sometimes they even incorporate information such as a calcium score and they spit out probabilities they say the probability of you having a major adverse cardiac events so heart attack stroke death in the next 5 years or in the next 10 years is x% and the consensus view here in the United States is you do not need to treat a patient for primary prevention unless that number is above some threshold typically 5% so if you're talking to a 39-year-old patient by definition it is mathematically impossible for them to have a five or 10year risk above 5 per. in fact most of the risk models don't even allow a calculation if age is below 40 in my case that was the case I first began to pay attention to this 15 years ago when I was 35 and there were no risk models so basically no one would consider having treated me preventatively even though my family history was significant I even had a spec of calcium on my calcium score which is a a symbol of late atherosclerosis um my view is that that's completely backwards logic it's backwards for two reasons the first is the time Horizon is completely wrong yes it's true that if someone's 10year risk is high we need to act dramatically but to wait until a person's tenear risk is high is tantamount to driving a car towards the edge of the cliff and telling the driver you're only allowed to hit the brakes when you actually see the edge of the cliff yeah as opposed to telling the driver I can't quite see the edge of the cliff now but I know that there is an edge there let's slow the car down but the second reason to me is even more frustrating and and I think if I'm going to be critical of the medical establishment in one regard it's going to be this which is there's often a failure to appreciate the implic of causality and causality is a is a complicated topic because it's so often confounded with correlation and Association but I'll spare The Listener kind of all of the details because I write about it at some length but there is no ambiguity about the causality of apob and its effect on atherosclerosis I don't know how much your listeners are familiar with apob and if it's worth explaining what that is but yeah P I was going to ask you so please do expand because it's also not a test that the NHS offer people in the UK either so not only is it I know very well a very powerful if not the most powerful predictor but at the same time it's something that people unless they pay privately here which is a very different model really don't have access to so yeah please do please do explain okay well the good news is first of all it's a very inexpensive test even in the even in the United States with our grossly and disgustingly elevated costs that are artificially inflated even in the United States the apob test is only on the order of about 20 somewhere between 12 and $25 so I would imagine that in the UK even if one were to pay out of pocket we're talking about a test that probably would cost less than you know 10 pounds um but putting that aside for a moment um a poor man's substitute for apob which I assume the NHS would cover would be non HDL cholesterol yeah um is that something that would be readily available to anybody yeah so non-hdl cholesterol is a poor man's surrogate for apob but what apob is is a it's a protein that's wrapped around all of the particles that cause atherosclerosis of which the most common is the lowdensity lipoprotein or LDL and by measuring the apob concentration you are directly measuring the concentration I.E the number of particles per unit volume of all the lipoproteins the ldls the vldls idls lpas that cause atherosclerosis and that turns out to be the most powerful predictor of any lipid or lipoprotein as it pertains to cardiovascular disease and what you want is for that number to be as low as possible in formal logic we would describe apob as necessary but not sufficient for atherosc osis so you need it to get atherosclerosis but by itself it's not sufficient to cause atherosclerosis which means that there are some people walking around with very high levels of apob who do not go on to develop atherosclerosis but you can't get atherosclerosis without it so we've established through epidemiologic studies primary prevention studies meaning the treatment of people who don't yet have cardiovascular disease secondary prevention studies the treatment of people with cardiovascular disease and mandelian randomization perhaps the most powerful of them all we can explain that if people want in a moment but I don't think it's Germain we've established through all of these different levels of evidence that lowdensity lipoprotein or apob is causally related to atherosclerosis this is so important again I don't think there are many doctors worth their salt that would not IGN acknowledge that so now the question becomes why would we not reduce dramatically at an early age the level of this lipoprotein and I would use an example that I've used before I think I us it in the book of smoking everybody knows that smoking is causally related to lung cancer meaning it's not just an association that we see a tenfold higher prevalence of lung cancer in smokers and by the way it doesn't mean that every smoker will get lung cancer or every person who has lung cancer was a smoker neither of those things are true but neither of those things diminish the causal relationship between smoking and lung cancer and because we know that smoking is causally related to lung cancer we take a very simple preventive strategy which is we tell people out of the gate do not smoke and if you do smoke stop right away can you imagine if we used models to predict the likelihood of people getting lung cancer and waiting until the probability of that event was you know 10% and then saying well listen Johnny your your risk of lung cancer is now 10% it's time to stop or let's wait until on the chest CT we see calcified lesions in your lungs that are suspicious for cancer now it's time to stop of course not once you've established causality you remove the causitive agent and yet we don't take that that approach in treating atherosclerosis which is why atherosclerosis is the leading cause of death globally 19 million people die every year from atherosclerosis number two is a distant second cancer 11 to 12 million per year atherosclerosis not only shouldn't be the leading cause of death it shouldn't even be in the top 10 based on the tools we have to delay its onset significantly yeah I really appreciate the analogy to smoking I think it makes it really clear how how backward shortsighted frustrating limited our approach currently is to how we look at these things what's really interesting is that you mentioned APO B and it's necessary but not sufficient in enough itself of course there's all kinds of other things I'm guessing inflammation immune dysfunction all kinds of sort of um ingredients to put into the mix really to can bust things up where you actually end up having the atherosclerosis but you also mentioned you want to um bring apop down as much as possible the lower the better now what's interesting about that for me when I hear that is most things in life I would say there's upsides and there's downsides right and often we just look at the upside and we negate or we we fail to take into into consideration what is the downside here so let's say APO b um let's say we've measured it and it's higher than we would want and let's say the patient is off a reasonably high risk I guess you would say by definition having a high apob puts them in a risk category of sorts the question then is how aggressively do you decide to lower it what therapeutic intervention do you use to lower it and then just to add on there Peter is we're talking about these four horsemen that end up bringing life to a close early right atherosclerosis cancer neurod degenerative disease and I think poor metabolic Health right it's ever scenario where you are aggressively attacking one Horseman to bring your wrist down off that one that's then inadvertently increasing your risk of one of the other horsemen yeah there is and I think staying on this example I think let's use two let's use two examples right so um we know that aggressive use of a class of lipid lowering agents called statins has a small but nonzero risk of increasing insulin resistance in some individuals in other words there are some people who when you put them on a Statin so a dose like ruva Statin atorvastatin things like that you reduce their r o which is the desired outcome but you get an undesirable side effect which is glucose levels and insulin levels go up and you are pushing them now further towards the risk side of the spectrum on the metabolic Health plane well that's a problem right because to your point if you're if you're solving one problem and creating another that's a suboptimal solution so we have to look for Optimal Solutions now the good news is where we are today we have so many tools for reducing apob that don't come with those side effects now the good news is most people and it's hard to quantify this but it's seems to be in the neighborhood of about 90 to 94% of people have no measurable discernable subjective or objective side effects to statins meaning they don't have muscle pain they don't experience elevations in transaminases they don't have insulin sensitivity issues or anything but let's just say 10% of people do we have pcsk9 Inhibitors we have aetam we have bendic acid these are drugs that really don't seem to come with any side effects uh sometimes when I look at the mechanism of action of a Statin I'm surprised the side effects aren't higher because it because of where it acts in the inhibition of cholesterol synthesis and how it does so ubiquitously in the body but when you look at how these other drugs work we don't I think need to go into the mechanisms of each of those I Do cover that very briefly in the book um it's intuitive that the mechanism of action of those drugs matches the clinical experience which is basically virtually nobody has any side effects to these other drugs they're much cleaner drugs than a Statin if we can use that lingo so um yes the goal is to get apob as low as possible we'll talk about how low that is um but you have to be able to do that without creating another problem and I think you know 15 years ago 20 years ago that was a much harder proposition than it is today before we go further piece just on that point which I think is a beautiful uh illustration of some of the kind of upsides and downsides that have to be weighed up if we move away from pharmacetical medication for just a moment and we look at these four horsemen and go okay what do we know that is probably playing a role in all of them most of them chronic unresolved inflammation would probably be something that most people would agree on is one of those core Roots causes that are going to increase the likelihood of each of those four so therefore if we can adopt uh certain lifestyle Behavior is that help us to lower chronic inflammation then those lifestyle changes are likely to aggressively start to reduce our risk of all four of those we're we're probably not having to weigh up you know lowering risk of one and increasing risk of another I first of all I I wonder if you agree with that perspective or whether you have a slightly different perspective and then following on from that is it only typically when we're bringing in foreign agents let's say a pharmaceutical drug that these considerations of you know improvment here problem here start to become an issue because you mentioned statins and of course statins are known for some to impair negatively mitochondrial function and then you write about Bally in the exercise section of the book about the importance of mitochondrial function for a whole variety of different reasons which hopefully we'll get to during this conversation so it it's kind of these upsides downsides upsides downsides that appears for many people if they're listening to this trying to take ownership of their health and I know your book's going to help them sort of walk them through this and try to figure out how they do this it it kind of comes across maybe as man is this confusing am I going to reduce my risk of atherosclerosis but at the same time increase my risk of type 2 diabetes so how would you help us kind of how would you help the general public you know look at these problems and what can they actually you know practically do to sort of manage this risk for themselves if at all they can all right so I think the first question was is the problem of whack-a-mole where you lower the risk of one only to potentially amplify the risk of another is that a problem we only see in Pharmaceuticals and the answer is unfortunately no uh in fact that's that's a general problem of Life there is no scenario that I am aware of by which you can take an action that addresses one issue that does not potentially have an impact on another so let's take two lifestyle examples quote unquote lifestyle examples where you have a clear positive impact in one Arena and a clear negative impact in another uh the first would be fasting okay or let's let's just be more you know let's just talk about caloric restriction extreme caloric restriction so there's only two interventions in the entire literature of geroscience that have reprodu reproducibly extended life in virtually every model organism across which they've been tested one of those is caloric restriction when you calorie restrict an organism it in a laboratory environment It generally lives longer there are some caveats but as a general rule you calorie restrict mice rodents flies worms everything they just tend to live longer do We Believe calorie restricting humans to 30% of their required caloric intake so a person who would normally need you know 2500 calories per day you're going to knock 30% of those calories off day in and day out do we believe that that is a net positive in their life and the answer is it is probably not because while you will have undoubtedly reduced their risk of diabetes and metabolic disease and probably by extension reduced their risk of cancer and maybe heart disease in the process less clear on the neurodegenerative side by the way you have undoubtedly and this has been demonstrated in animal models increased their susceptibility to trauma and infectious diseases in fact those people are very likely to end up in a case of sarcopenia they're far more susceptible to one of the other great Horsemen that doesn't quite rise to the level of being the big four but it's a very close number five and that is accidental death which is virtually entirely dominated by Falling once you reach the age of 65 so these are individuals who lack muscle mass who lack bone mineral density and the mortality from a hip fracture or pelvic FL fracture when you reach the age of 65 approaches 30% in the first 12 months yeah so you solve one problem you create another and that's again just dealing with something that's as beneficial potentially as choric restriction let's take another example if an individual goes from never exercising at all to exercising to an extreme level they might get injured right they so they're going to acre lots of cardiovascular and muscular benefits of exercise let's say they take on a very aggressive regimen where they're you know running an hour a day and lifting weights for two hours a day there's an enormous benefit to that but if they themselves and I mean a bad injury you know they damage a disc in their back that ultimately requires a twole fusion well that's going to have a terrible outcome on the duration of their life not necessarily in terms of how long it is but in terms of the quality of life and the pain that they're in so so I just want to make sure that everybody understands that everything we're talking about has a trade-off and that's why we have to be nuanced and we have to apply the right tool at the right time and I I think what you know what I tend to to bristle against is the idea that we would individually or collectively view tools as binary Goods or bads yeah right you know and and I get this question all the time of course I'm sure you do which is are statins good or bad uh you know is metformin good or bad and it's sort of like that's the wrong question right that's like asking a carpenter is a hammer good or bad is a screwdriver good or bad well it depends what you're using it for and it depends if you know how to use it you know if you try to take a hammer to a Phillips screw that's a suboptimal use case if you try to take a Phillips screwdriver to a nail that's a suboptimal use case so we we yeah we have to get away from kind of what I call paint by numbers into sophisticated nuanced approaches to pharmacology exercise nutrition sleep Etc what qualifies a strength right the reason I asked that question is because let's see you're a runner right and I personally think running's fantastic it's a very innate human movement it's you're loading your um you know you're interacting with the ground you're putting load through your joints through your tendons if you're doing heels that is a form of strength training for your legs right so if you're a runner and yes this is lower body not upper body if you do heill repeats regularly does that qualify strength training probably not because it's still a high enough number of reps that it's not hitting the type two muscle fibers okay um as evidenced and by the way even when I'm walking up a hill with a 100 pounds on my back up a 15% grade I'm still doing so many reps that I'm mostly fatiguing my type 1 fibers okay so even though it's you moving your body weight Against Gravity with which is a form of weight y it doesn't quite meet the threshold for working on that particular T fiber that we are going to need when we're 70 or 80 stepping off a curb right so a better example would be doing a box step up with weight in your hands you know there like if if if you so getting a box getting a bopping up onto it up and down up and down holding weight in your hands and if you did that such that you could you were literally you know so we typically talk about doing these sets until you're at one to two reps in reserve so you don't have to go to failure when you're lifting but you want to go until you could only do one or two more reps at and that would be failure and if you're loaded to the point where you're getting eight to 20 reps in but meeting that criteria your one to two reps in Reserve at at the most by definition you're now recruiting type two muscle fibers you've fatigued all the way through the type one and your type two so you'll and and as a runner you'll appreciate the difference in what that burn feels like versus the burn of of running hill repeats again there's a lot of benefit in running hill repeats um and you're taxing your V2 Max and you're doing a whole bunch of other things um and by the way as a runner you'll benefit from the strength that comes from those box CLS okay fascinating so that was one component so he'll repeats doesn't count you're looking at something that's just one or two short of your maximum which I think is very helpful very very specific for people and again in terms of making this accessible to people that's a relatively you know a box step up you know it's kind of most people have access to that right yeah the when it comes to lifting weights especially if you're just starting out I mean the amount of equipment you need you can do this at any hotel you can do this at any it doesn't have to be a super fancy gym um you know carrying dumbbells doing what's called a farmers carry such an important form of activity um both for your grip so most people will find when they initially do this and we have standards for our patients when it comes to these types of exercises whether it be box step UPS um Farmers carry you know for example for a woman we want her ultimately uh and we Index this by decade but say a woman in her 40s should be able to carry 75% of her body weight in her hands for a minute so if she weighs 100 PB she should be able to carry 75 lbs 37 and a half in each hand for a minute and if she can do that it me can if she can then she it means that we are very confident that by the time she's in her last decade she will have the strength to open a jar for example do the Ty of things that we think really matter to people yeah I love that it's really specific cuz anyone any female listening to the show right now can actually go and check that themselves see what am I able to carry now if they cannot let's say they go okay this sounds great oh wow I can only do 20% or 30% or I can only carry it for 20 seconds and then my grip Fades out yeah so what's the advice then it means drop the weight so say go to half your body weight until you can get to a minute go find a weight that you can get to a minute and then slowly Advance the weight that's brilliant really really practical and for a man it's your body weight for a minute so at what age again in your four in your fifth decade so between the age of 40 and 5050 so for example if the man weighs 180 PBS he should be able to hold 90 PBS in each hand and walk for a minute yeah I love that and again a lot of people will not be able to do that out of the gate that's fine drop it down go to 70% of your body weight go to 50% of your body weight um it's interesting a lot of people get put off strength training they think it's a they may never have done it as a kids they they may be intimidated by gyms they may not know what to do and think ah man I can't afford a personal trainer I don't know what I'm doing the farmers carry is is kind of something you know I guess you got to be mindful that you're not sticking your head out right that you've got a decent decent alignment and yes you probably need some body awareness but it's it's quite an accessible thing that people could try themselves I think yeah for sure and we we've um I can't remember if we included the farmers carry in the video for the book but there are there's a there a series of videos we made to go with the book it's on your website right yeah yeah um so so it's we there's probably at least the show not yeah there's at least half a dozen of the exercises including the step up where we show the correct form because you're right you can you can cheat you can do these things incorrectly there's a lot of ways to to do this and we always have people start these things with just body weight for example in the step up you know before they move to any weight staying on strength let's talk about grip strength and foot strength the extremities of our body why are they so important maybe there's a lot of data on grip strength yes but what's fascinating for me and you'll explain the DAT I'm sure on grip strength but that might indicate to someone I need to get my grip stronger so I'm going to buy by those little grip squeez by those little grip squeezes and just get really really strong grip T which I I'm not entirely convinced it's going to do what we want it to do so maybe expand out on that if you can yeah so I think the same reason that V2 Max is such a remarkable proxy for lifespan and health span is why grip strength always seems to be a remarkable proxy for both as well and it comes down to what they are indicators of or what I like to describe as integrals of so you know how a hemoglobin A1c is at least in theory supposed to be an integral or summation of what your blood glucose has been like over the past three months similarly a very high V2 Max is an integral of very hard training for a long period of time yeah if you took an unfit person and said I want you to train really hard for a week they're not going to have a high VO2 max in a week in fact if you took a person at the bottom fifth percentile and had them exercise for three months they're not going to get to the top fifth percentile that's why a person at the top 5 % of V2 Max you can tell has years of training that's what it's telling you so it's such a good predictor of lifespan because it's reflecting so much more than we can ever get out of a questionnaire tell me how much you exercise a week and how strenuous it is who cares like all those inputs are reflected it's totally and it can't be hidden it can't be masked it can't be cheated yeah the same is true with grip strength grip strength is an integral for overall strength you can't be very strong without having a strong grip right so I think about being in a gym and lifting weights you're always using your hands um I'm here in London right now we're at a hotel I was deadlifting yesterday and I I sometimes bring liquid chalk with me because you know if you're at a gym and they don't like you to use chalk you have this liquid chalk and I forgot to bring my liquid chalk and so I had to deadlift without chalk yesterday and it's just a stark reminder of how I become grip limited when I'm deadlifting in other words like I was failing because I couldn't even hold the bar anymore so I actually ended up dropping the bar at some point not because my glutes and my quads and my legs were I was limited by my grip and you start to realize so much of what I'm doing in the gym is driven by my grip strength yeah when I'm doing a pull-up if my grip is failing I'm failing and that's why farmers carry of course is such a good functional exercise that's right yeah you're using your grip so often when you are strength training and so it's true that it's an easy thing to measure and that's also true with V2 Max it's objective scientifically measurable reproducible you can measure it here in London you can can measure it in San Francisco you can measure it in Delhi it doesn't matter where you are you can always measure this same is true with grip strength leg extension chest press I mean these are the things that they typically measure but it's you you know it's you're always going to see the studies talk about grip strength and I agree with you completely it it's it's a bit misleading because people think great I just need to go get a little squeezer thing and it's like no definitely don't get a little squeezer thing go pick heavy things up and walk around yeah there's something about that the extremities isn't that that how we interact and carry things but our feet are how we interact and that's the that these are the the hands and the feet are the Force transmission to the outside world yeah and my I was going to say bias but yeah I I was trying to be aware of my own biases I personally have been wearing Minimalist Shoes for over 10 years now they've been transformative for me I've recommended them to so many patients over the years not everyone but many of them and I've heard and seen so many improvements now again you got to be careful I'm not talking about going from wearing cushion shoes your entire life to suddenly trying to run marathons in minimalist years no no let's let's be logical let's be rational about this but I wonder what your perspective is on foot strength how it relates to what you just said about grip strength and potentially where minimalist and barefoot shoes may fit into this part of the conversation yeah I mean I have the luxury of kind of because I work out at home I I work out Barefoot so I I do really enjoy being Barefoot as much as possible um and I think that um look the feet are very similar to the hands um in terms of musculature what I think most people would appreciate is we have much more dexterity with our hands than we do with our feet and um a part of that is the fact that our hands are never really restricted the way our feet are so when we're in tight fitting shoes constantly uh so in other words it's not just being in a minimalist versus a non-minimalist shoe it's kind of like having your toes jammed together pointed toes yeah you know 12 hours a day uh that creates for a difficulty in using the foot the way it was kind of meant to be used so for people who have kids look at your kids feet yeah you you see what happens yeah so so um anyway long the way of saying I I I completely agree I do think that the the the shoe industry has kind of um probably gone uh to a to a place where we've we're not making healthy feet and many people myself included have had to spend a lot of time undoing uh the damage of of wearing shoes too often and very tight shoes and you know interesting there was a study done at the University of Liverpool a couple years ago and to be fair this study was done wearing fivo barefit shoes and to be completely transparent they are one of the supporters of the show um and I was make it clear that I was buying them with my own money for seven years before they started sponsoring the show that being said that study showed that um adults who were wearing these Minimalist Shoes over four to six months for just regular activities going to work going to the shops going for a walk not for running or not for going to the gym just for getting on with their day I think from recollection the foot strength went up by over 60% which I found remarkable because you're not actively trying to get a foot workout in you're just wearing something that allows your feet that that results in your feet having to do more work than when they're completely cushioned yeah which is which is pretty incredible so strength I just wanted to before we move on from strength just touch on females there are some unique uh pressures on women especially postmenopausally and so I just want if you could speak to that when we're talking about strength training yes it's very important for both men and women but are there particular reasons in your view why women need to pay special attention in part I mean there are several but in part I think uh on average women come in for example to our practice or you know in in Middle adult uh middle age they've done less strength training than men um of course we use nomograms that are sex specific so we when we're looking at metrics of muscle mass we use something called appendicular lean mass index and fat-free mass index so those are going to be normalized to age and sex um but uh you know women are often coming in having done less strength training so they're going to have less muscle mass is that a problem yes yeah strength and muscle mass are positively associated with lifespan and health span for men and women equally and um there's a big step up once you're at the 75th percentile so in other words the top 25% compared to the bottom 25% for muscle mass is a pretty significant difference uh in terms of risk of all cause mortality okay so let's just imagine two scenarios here a teenage girl or there's a parent listening and they're concerned about their their daughter let's say maybe their son as well who's a teenager we've spoken a lot about the decline that happens in your 30s and your 40s are there things we can and should be doing with our children with teenagers to insulate them even more oh if you if from this decline absolutely and and I'm glad you brought that up because um bone mineral density has a strong genetic component um however you achieve your genetic cealing or your genetic potential by your early 20s and so if you if you think about the implications of that it means that people who are not doing the types of activities and again strength training is the most important activity on the list if you're not lifting weights as a teenager into your 20s you're not going to achieve your genetic ceiling and everybody both men and women are in a state of decline for bone mineral density from your early to mid 20s on for the rest of your life so if you're before that if you're listening right now and you're a teenager or if it's a parent we should be doing whatever we can to encourage our children or yourself if you're that teenager to be lifting heavy weights until at least 22 23 well beyond but beyond but there's this beautiful window in which you can capture your your your genetic potential okay and um again everybody male and female will start to decline from about the mid 20s onward women have a much more precipitous decline at men pause if they don't go on hormone replacement therapy so estrogen is the most important hormone in bone health for both men and women and women lose their estrogen precipitously at about the age of 50 if they don't go on HRT so in that sense women are more susceptible and um it's not uncommon to see women at the transition to menopause who haven't been lifting weights even if they've been very fit and they've been exercising um they show up with osteopenia uh wow and I mean we we see this too often two things to to to comment on there one is that makes me feel better about some of the uh disagreements my wife and I often have if the if a new kettlebell delivery has come at home and I have them lying around and the kids are picking them up and playing with them and my wife's like no no put it down you'll hurt yourself I'm like hey let them let them pick it up right of course there's injuries to consider you got to be safe but I just think you know what kind of let them do pick it well it's funny to say that I mean my um my two boys who are uh one just turned six the other is eight they've really become interested in coming in the gym with me in the past year and um I've just started them doing kettle bell lifts so it's a deadlift basically with a kettle bell so they're standing over a kettle bell and you know at first I just had them doing it with the lightest kettle bells and they were really getting annoyed and they really wanted to start lifting heavy things things so I said okay guys on the condition that you can listen to me and you can do this properly and actually it turned out to be really challenging to cue a five and six-year-old to do a deadlift because I can't cue him the way I would cue you yeah I can't tell him about intraabdominal pressure and thoracic extension and stuff it has to be much more simple so the first thing I realized when I was watching him pick it up is he was doing it incorrectly and I was surprised I thought a kid will always pick something up correctly but he didn't he was using his back and not his legs and I was like why is he doing that and I realized oh immediately like his arms are bent if you don't have tension in the arms if you don't have profound tension in your arms you can't use your legs if you have any laxity of tension in the upper body and he was bending down so much that he was like grabbing the thing this close and then trying to pick it up with his back so anyway it was a great exercise for me to learn to cue him correctly but then to watch how perfectly they can lift things um and now it's like okay so he just comes in the gym and all he wants to do is pick up that kettle bell up and down up and down up and down how old is he he just turned six a couple weeks ago I love that yeah I love that and obviously he wants to do what Daddy's doing and Daddy's lifting stuff I want I want to do that as well so we can harness that potentially yeah um but the point is this is so important for for teenagers and um again you you may you mentioned something earlier that I think is a is a troubling and and upsetting statistic which is you know that over whatever period of time I can't remember 30 years I think you said there was a 90% 90 second loss in one mile time you know unfortunately I'm sure there was a a comparable statistic for loss of strength as well um so basically with kids teenagers we want to be encouraging this early of course the same is true with Fitness in other words you like I I feel very fortunate that you know even though I don't train at a fraction of the level that I used to I think the part of the reason I can maintain a relatively high level of Fitness is I maintained an absurd level of Fitness as a teenager into my 20s so in other words I reached a genetic ceiling then that I think makes it easier for me to stay in shape now and again that shouldn't mean that anyone who arrives at 50 who's not in shape should be discouraged you in many ways they have more potential they have a potential to be higher than they were before I don't I'll never be as high as I once was um but I'll probably be higher than that person on account of the fact that I had that capacity so young so we you know again to your point if you're listening to this and you're a parent or a teenager you really want to make sure um your kids are fit of course one of the four horsemen is metabolic health so maybe we could just briefly speak to you know metabolic Health what is it and why do you think that a CGM a continuous glucose monitor is potentially more helpful for us than the standard Market that we have for example hba1c which is that two to three month average blood sugar measurement that many people have um ready access to yeah so I'm going to guess that you're you're uh your listeners know what a CGM is it's a device that you you wear it's implanted in you it has a tiny filament that REM like there's a needle that inserts a filament the needle comes out but the filament stays in and it stays in um the you know basically the subcutaneous tissue and it samples interstitial fluids so it's not actually measuring the glucose level in blood directly but it is indirectly doing so by measuring the glucose level in the interstitial fluid of the subcutaneous tissue and it is calibrated to then know how that translates to glucose so if it's working well and that's a big if um it's giving you the real time maybe delayed by five minutes reading of your blood glucose so why is that important well I think first of all it's important for patients to understand how various factors impact their blood glucose and the reason for that uh again comes down to understanding the relationship between average blood glucose and gluc because variability and health and at the extreme levels this is not disputed in other words there's I I have yet to meet a person who has tried to argue um which isn't to say that somebody's not trying to argue that but I certainly haven't met the person or read the argument that type 2 diabetes is harmful in other words that when a person's blood sugar averages more than 140 milligrams per deciliter which is the cut off at a 6.5% a hemoglobin A1c that poses increased risk to an individual relative to a lower hemoglobin A1c that is beyond outside of the diabetic range so the question then becomes well what if you don't talk about it through the lens of type two diabetes so if you took a hemoglobin A1c of 5.7% or 5.6% which would translate to approximately 120 milligrams per deciliter in our units uh that's probably about six Mill in your units right um and then the question becomes how does that compare to a hemoglobin A1c of 5% so now we're talking about two people who have neither diabetes nor type two or or pre-diabetes and we're asking how do two quote unquote normal blood glucoses compare when one is higher than the other one is say 120 and one is 100 well it turns out that that analysis has been done we've written about that and the analysis this is pretty clear there is a monotonic decrease in all cause mortality as average blood glucose goes down even within the normal range outside of type 2 diabetes similar analysis exists for other parameters of glucose and so the takeaway here is that things that can result in a lower average blood glucose even in the normal range I.E below the type 2 diabetes threshold are probably beneficial for all cause mortality and so therefore by measuring those things using a hemoglobin A1c would be the crudest way to do that there might be an advantage to measuring that in other words you you would you would tell a patient whose hemoglobin A1c is 5.6 let's work on getting it down to 5.2 even though both of those patients are considered normal and can I say Pizer just that I just want to highlight for people that that is what you've just um laid out there for me is one of the big holes in how we currently practice medicine it is normal but not optimal it's the the the the the lack of recognition that these things are on a Continuum and we don't want to wait until it's too late we want to get involved early so please continue I just I I I think it's such an important point for us to get for all of us to understand no thank you for making that point actually that's a more eloquent way to to say what I was trying to say which is we tend to confuse normal and optimal and they should not be normal is generally a term that's reserved for being inside the extreme ends of a bell curve right so if something is normally distributed on a bell curve we might say you're normal if you're above the fifth percentile and below the 95th percentile you know the 90% of people that are not at the extremes are quote unquote normal but that says nothing about being optimal and this is true with blood glucose this is true with kidney function this is true with apob this is true with liver function tests transaminases it's true with hormones it's true with everything so um the CGM is a tool that offers at least a couple of advantages over I would say three advantages to be clear over measuring something using a hemoglobin A1c the first is the hemoglobin A1c tends to be inaccurate in any scenario by which red blood cell life is not exactly as predicted by the assay so the you know just so folks understand hemoglobin A1c is something that is directly measured you draw the blood you measure the amount of glycosilation on the hemoglobin molecule that's the number you get that's the 6.1% or the 5.7% the average blood glucose is imputed not measured it's imputed from the hemoglobin A1c based on a belief that the red blood cell lived about 90 days but if that red blood cell was in circulation for a much shorter period of time for example in a person with lowgrade anemia uh either due to Red Cell turnover or bleeding low grade bleeding you're going to get an artificially low estimate of their average blood glucose because the red blood cell hasn't been long enough hasn't been in circulation long enough to accumulate the glycosilation so if it comes back at 5.0 and you assume their average blood glucose is 100 you're grossly underestimating it similarly conditions that lead that you would also see this by the way in macro anemia and things like that you would also see the reverse in conditions where the red blood cell sticks around longer so microtic conditions such as betaal trait and things of that nature that result in small red blood cells that aren't getting chewed up at the same speed through the spleen you're going to see longer residence time of red blood cell you're going to see artificially elevated estimates of hemoglobin A1c or average blood glucose Vis hemoglobin A1c so that's the first reason a calibrated CGM and I do insist on calibrating them when I use them I don't rely on the manufacturer's calibration so I insist on doing calibrations the entire time I would wear a CGM a calibrated CGM is a far more accurate tool to measure average blood glucose and glucose variability the second reason is that the person using it even if they only use it for a month and never put it back on gets a far more profound relationship or Insight relationship to how various factors most notably what they eat how they sleep how they exercise and what stress is doing they get to see how those things affect blood glucose and those are you know having now used a CGM on myself and with patients going back eight years there there is simply I I've yet to meet a person who isn't amazed the first time they wear one at those relationships yeah wow I didn't realize how eating in the evening is different from eating in the morning how eating after I exercise is different from eating when I don't exercise how sleeping six hours a night changes my blood sugar the next day versus sleeping eight hours a night how being under stress versus not under stress I mean the differences are so pronounced that people are really blown away so there's this phase of what I call Insight generation for which there is no substitute and which can't be done without real-time feedback and then the final reason and this is more for people who like me find Value in using this tool beyond the state of insight it becomes a bit of a behavioral tool yeah so if I'm wearing a c g m and I go into my pantry and I see a bag of my favorite junk food I'm less likely to consume it when I'm wearing the CGM there's just a gamification that goes on with me where H I don't want to see the number go up I don't want to see the number Skyrocket because I ate five cookies so I'm just going to be better at not eating those cookies and for some people that doesn't that doesn't mean anything they don't need that they might have the willpower to do that uh to avoid those five cookies without the CGM but for many people it is a valuable tool opponents to wearing cgms will often say it could promote disordered eating or an unhealthy relationship with foods and of course for some people it could be yeah I agree I I I agree with that completely I think um we are very careful in who we prescribe a CGM to and if a person has any history of disordered eating and we do have patients in our practice who do we simply don't use CGM as a tool and we're very careful about other things as well such as you know macr tracking yeah um you know so so yes of course this is an example of nuance which again I think the listener by this point of the podcast understands if there's something that has to underpin everything you're doing in medicine 3.0 it is Nuance yeah for sure and yeah so you you have to be mindful of who you apply the treatment to you know I I'm currently on my Journey with cgms I would say I put one on for two weeks every three months or so I found that for me that seems to work quite nicely I I get some insights I then don't wear it I apply those insights and then I I pop it back on a few months later to see where I'm at it can help me modify often if I've fallen off it helps Focus me but again that's what works for me and I'm sure for some people it'll be less for some people it might be more and of course for some people it may be never but I have yet to see something more powerful in two decades of practice as as you just highlighted at changing behavior um we have mentioned blood pressure and it's really interesting to me observing your journey and reading your book as to when you came across emotional health as a key part of the Health and Longevity conversation and I feel that emotional health for me both because of struggles I've had personally but also with patience I don't know if this Rings true to you or not Peter but I always used to observe people and go people say information is power okay great I don't disagree with that statement but what I would see is that patients would make changes we together we'd help them make some changes to their lifestyle you know again that term lifestyle their life their life behaviors let's say and they would start to feel better and sometimes that would be 1 month sometimes they'd be doing it for four months or 6 months and their life would be transformed and they'd feel good they'd have energy better relationships better sleep whatever it might be but often people would then flip back to where they were before and I would observe this with patients and I would think okay why is this it's clearly not an information problem they they they know the information they've not only know the information they've experienced they can feel when they apply these things why are they going back now of course there's many different reasons but this is the sort of topic I covered in my last book was that I thought well is lifestyle really the issue here or is it something further upstream and I I really have come to the conclusion that actually it's something more Upstream than that it's how they approach the world it's how they deal with conflicts it's how they manage their relationships because when there's problems there with let's say emotional health and I think the chapter you've written on that is brilliant I think often our lifestyle choices are Downstream consequences of them so one of the reasons I went down this road maybe 5 10 years ago is because I thought no I need to tackle this I also feel Peter I'm sorry for the long-winded start to this point but um um trying to get a couple of points across it feels to me that you throughout your return to Medicine have had access to a lot of testing so you can do a lot of testing with your patients for whatever reason that may be whereas as someone who has typically spent most of his career in the National Health Service not having had access to testing means that I feel I've had to really pay attention to other things so I don't have the testing so what's going on here or they're telling me these words what's the story behind their words and so I feel maybe the different ways in which we practiced have meant we've come to this from slightly different approaches so a couple of things there Peter I wonder if you could maybe give me your perspective on what I've just said no I think what you said is beautiful um and and I think that's such an amazing way to think about the differences between you know the to the two ends of you know opposite or extreme ends of um how you know we could talk about two different practices right so I'm sitting here in the United States which is a private health insurance only right there is no National healthare and even within private insurance you know you can move from insurance to just pure fee for service and you know the US is sort of the sky is the limit when it comes to testing testing testing we can do anything and everything right you're at the other end of that spectrum and yet you're absolutely correct I think that our system pays very little attention to the problem that you address and I think it's very astute and I I I'd be curious you know to know what fraction of Physicians within the NHS would recognize what you've recognized which is look I have less at my disposal right now in terms of fancy tools so I'm going to rely on more of these human tools these interpersonal tools these skills that once made a physician what a physician was and I'm going to rely on those to try to better understand how I apply the fewer tools that I have so no I think I think that's that's really interesting of course um you know my foray into this as an interest was was very personal right it started through my own experience um and I I I would say that prior to my own experience with it I was not necessarily that attentive to how much of a struggle maybe others had and how much of a role this played in the behavior of other people especially in the examples that you use around you know the ability to make changes and then the ability to sustain changes you have shared very openly in the book but also in some of the podcasts you've already done you've you know really opened up about some very very personal things in your life uh parenting things with your wife um your your your child being sick when you were I think in New York and it's really interesting i' I've been listening to those as part of the preparation for our conversation pizza and I know that you have and I think you've admitted this you have perfectionist Tendencies uh or you've certainly had them for much of your life I'm really interested as to what it's been like for you as someone who for much of their life I think at least has seen thems as a perfectionist being on these large platforms these large Global platforms and now being truly quite vulnerable sharing things about yourself that potentially a former version of you would maybe not have admitted to yourself certainly not shared to hundreds of thousands of people what's that experience been like for you like have you reflected afterwards have you after these conversations thought oh man did I say too much like what has it been like for you on a on a sort of human level well it's very uncomfortable I mean I don't think um I appreciate you thinking that maybe I'm a former perfectionist I think I'm a perfectionist in recovery and uh like I think any addict we you know I think we have to have humility around our addictions and uh and keep a close eye on them so um I I think I'm always going to struggle with vulnerability and with um with letting people see my faults and acknowledging my faults and my own Humanity to myself that said um I also realize that I'm very lucky and that um you know I think to to whom much is given much as expected and so to be sitting here having this discussion to have you know survived the ordeal of my you know my past and what I went through in you know 2017 2018 2019 and 2020 um relied on me being very fortunate meaning I had a lot of people around me and there have been some people who have commented to that effect which is hey you know most people don't have the resources you have to the help that you got right you know you went and spent you know I was five weeks collectively in an inpatient Residential Treatment Center um and that's that's not something our health insurance pays for here in the United States I mean that's I don't even remember what that cost but it was a lot um and and I have access to these incredible therapists and so that's not lost on me that there are many people who can't necessarily afford either in time away from work or in financial cost C what I have been very fortunate to afford and while I can't apologize for those things I'm not going to apologize for my good fortune what I am going to say is how can I pay it forward right how can I take my fortune my blessing and help other people with it and I think the best thing that I Can Do Is Write a chapter like the last chapter in this book and be open about my story even though it doesn't feel good doesn't feel good to talk about or write about these things the way it feels you know easy and autonomic to talk about exercise and sleep yeah thank you for sharing that you know perfectionism is a growing problem actually I was reading some uh research um from a psychologist in London recently how perfectionism is growing across the world um there's a particularly dangerous form of perfectionism social perfectionism about what we think other people think of us which if we just break down that you know we think what they think about this it's it's based upon a lot of assumptions that we may not know what they think and we're imagining what people think of us and and and the link between social perfectionism and suicide so i' I would also describe myself as a perfectionist in recovery um I I often think about it in terms of you know when there's a gap between our ideal self and who we actually are our actual self in that Gap the greater that Gap the greater the inner conflict I think we experience that's how I I've been thinking about it recently um but you're right it is uncomfortable you know you know you mentioned that you think you will always struggle with being vulnerable I I find that interesting and I've also heard you say in previous conversations Peter that you know given that it's taken me 40 50 years to get to this point I can't see this going quickly it's going to take a long time to go as someone who's maybe been on this journey since my father died in 2013 I don't think it necessarily needs to take as long as people think I I really don't and and I really feel that with again it depends on access of course i' done a sort of the a form of therapy called internal family systems Peter um by Dr Schwarz yeah which has just been incredible really incredible about going back into childhood situations reframing them and then you know when you sleep with consolidation and reconsolidation in the brain you almost lay down a new memory of what has happened it's really been quite profound so I as as someone who also described himself as a perfectionist in recovery I I would like as you know as a fellow human to say to you I I don't think necessarily it is something we always have to struggle with I do believe that we can I I passionately believe that we can get to the root of these things and rewire them and change and and I've certainly come to the belief piece that a lot of our personality is not who we are it's simply who we became and if we apply ourselves to certain practices we can actually change how we should Europe in the worlds um when I say that to you Peter or when I share my view with you um does it hit do you push back do you think nah I'm a difficult case it's going to take me a long time I mean what what comes up for you when when I sort of share insights like that oh no I I completely agree and I if I think about the progress I've made in three years um it's it's profound I mean I'm not the same human being I was three years ago that there's no comparison and actually I think I talked about this on the podcast with with Andrew huberman or maybe it was on with Rich R but it was one of those two where you know one of the hardest things for me to shed um or one of the first things I had to go after was the inner monologue which which was a very very destructive U inner monologue and it was something that I had never not known so there was never I don't have a conscious memory of not having this harsh at times violent awful voice that would speak to my speak to me and and not just in silently like it would do so audibly as well so if I made mistakes um you know I was G berate myself for them and it didn't take a rocket scientist to know that a big part of the problem was was you know what was at the root of that and then how could we fix that because that was then leading to so much other problem and conflict my life so without going into the details of it um because I do so on those other podcasts which um we can talk about if you like but the process of undoing that which was a was rooted in a very daily deliberate Behavior practice um took maybe six months to undo that voice so that surprised me because I really did believe that that was a permanent feature of my existence that was as permanent as my height or my eye color um and I was very surprised delighted that you know the the the the plasticity um of of the human mind could allow me to kind of rewire that in only six months and now admittedly of working very very hard in those six months but yeah that was that was very pleasant so no I'm actually incredibly optimistic that you know 10 years from now I'm going to be you know in far better shape than I am now emotionally might not might not be physically and cognitively as sharp at 60 as I am at 50 but I think emotionally I'll be in a better place and the in other words I think the trajectory is positive thank you for sharing that going back to what we said earlier on of the conversation physical cognitive emotional and of course we were discussing how you know physical and cognitive get worse with age and I was sort of saying yeah as you were just demonstrating there I think emotional can get better with age actually and I don't know maybe counter right someone that other stuff potentially but that's that's a much uh deeper and and longer discussion without sort of going back into the detail you have already shared on those other podcasts I think what might be useful in terms of a practical tool is simply sharing what you had to do to change the negative voice in your head because clearly negative voices in our heads are so common yours sounded particularly brutal I must say when I heard it I did iiz elements of it as well in myself um but to see that change dramatically in six months I think is really empowering would you mind sort of briefly sharing what that exercise was that enabled you to do that sure sure so um the the voice was basically uh the voice of a guy a very famous college basketball coach former basketball coach in the US named Bobby Knight so Bobby Knight was this insanely angry maniacal you know Savant of a basketball coach but who ultimately lost his career over his temper um and every every game was like a witnessing some crazy temper tantrum that he would have um and so the exercise was framed as you know you you have a board of directors that runs your life the board of directors in your head and unfortunately this guy Bobby Knight is the chairman of the board and we have to get him out of the boardroom um we have to get him far enough away from the boardroom that you don't hear him talking all the time so the way we're going to do this is every time you hear him talk and that's going to happen anytime you do something in the pursuit of um what we would call performance-based esteem so basically most things I'm doing in life I'm doing so that I can uh generate self so just as an alcoholic might turn to a drink or a gambler might turn to a slot machine I turn to Performance as the drug that's literally the drug that I need to have the the self-esteem and anytime those performance-based esteem uh activities fail to generate esteem because I fail in the activity I turn the rage inward just as an alcoholic would be furious if he walked into to a bar and asked for a vodka and received a water he would be furious at the bartender that's basically the cycle that's happening so the exercise was every time you feel that happen I want you to imagine that it is your closest friend that committed the act in which you failed right so for example if you're in your driving simulator and you know driving is one of my huge passions so if I'm not on a racetrack I'm in a simulator and you're having a bad day you're just not driving well you're spinning you're crashing your your times are slow whatever it is normally you would get out of the simulator and you'd be yelling and screaming and sometimes even break the simulator instead imagine that your closest friend was the one in the simulator who drove poorly what would you say to him and you know to do this exercise you have to be able to picture the person and so for this exercise I would typically pick a friend of mine named Matt Walker who you may recognize Matt Walker wrote The Great Book on sleep and Matt's a very very dear friend who is also a total Motorhead Gearhead uh loves cars whenever he comes over here the two of us are going to be in the simulator the whole time so I would look at Matt I would picture Matt close my eyes and I would imagine what I was saying to Matt if he drove that poorly and of course it would be very kind very loving very supportive and I would record that discussion on my phone and I would send that recording to to my therapist so two or three times every single day my therapist would be getting one of these five minute voice memos from me where I would be talking to one of my friends in this type of a situation and that was simply the exercise we've had the advice before on this show particularly when I spoke to Kristen nef uh who's done a lot of the research into self-compassion yeah you know talk to yourself as if you were talking to your best friend or a young child and I think we intuitively get that but I think what makes your exercise the one that you were given to do so powerful there's an extra component of accountability it's not just oh yeah I wouldn't say that oh come on change the record in your heads no you have to record that message and send it to somebody who is going to hear it so maybe you just speak to what was so powerful about sending it was it embarrassing will you read it will you think oh man I have to send this to someone like was the goal that you then play them back to you to sort of subliminally change the messaging you give yourself or or or just just give us a little bit more detail there if you can well I think that I think the recording is important because I think when you say it out loud it's much more powerful than just thinking it so it's one thing to say okay I just you know shot poorly in the with my bow and arrow or I drove poorly in the simul later I'm going to now sort of think nice thoughts but the reality of it is Bobby's voice is too loud for me to outthink him in silence I have to outspeak him right this is the the the mind works through concentration and there is there are very few things that can harness your concentration more than the audible sound you make with your own mouth so I have to outspeak this otherwise very loud force in my mind who by the way sometimes would actually speak to me right I would sometimes actually speak what he was saying so I I have to one up him in volume and then secondly the recording it and sending it is not about being embarrassing it's as you said it's accountability it's there's a person who knows that two three four times every day I engage in some behavior that is demanding of my perfectionism and is a vehicle for which I generate self-esteem and therefore I'm going to have commentary so it's it's really those two things and and so therefore by forcing the audible overwriting of a historical way of doing things I'm rewriting and by having the accountability I'm making sure that no matter how much I don't want to do it I do it going back to what you said before Peter about having the means to pay for a residential impatient facility to deal with a lot of the inner conflict you were feeling at the time and wanting to pay it forward I'm just trying to think is there something there in that exercise that people at home can actually utilize themselves for example of course it's not the same as having a therapist I understand that but just as if for example you're recommending to a patient to work out more whatever that may mean you May sometimes I'm guessing you know ask them to have an accountability partner who can show up with them to make sure that they're doing it and they can help encourage each other together could a version of this be with a close friend someone you trust per perhaps your partner could it be that you go actually you know what I'm going to ask them if for the next month I can do that exercise with them would they be willing to be that person for me do you think that could be a good thing or do you see any potential problems with that I'd have to give it some thought but my my inclination out of the gate is probably not to select a romantic partner for that exercise I think that probably would introduce some unnecessary strain on a relationship but I think it could be done with a friend that might not be as ideal as a therapist because the advantage of doing it with a therapist is you know in my case once a week I'm going to talk to that person as well and we're going to process those things and by the way some of them were just so significant that she would just call me right away right like she would listen to it and you know call me an hour later just to check on me or something like that so there's something to be said for that but I but I think if the alternative is not doing it yeah then doing it with a friend I think would be you know a far better option than not doing it are there any practices you try and do on a daily basis or at least a regular basis that keep your emotional health in tune or is it something you just go to from time to time no no it's a it's a huge deal and in fact when I left PCS which I write about in the book it's the place I went to in Arizona in 2020 um you know I had a recovery contract that I made and the recovery contract had red light behaviors yellow light behaviors green light behaviors so red light behaviors were things I never ever ever wanted to happen again and if they happened I understood that that was a trip back to rehab yellow light behaviors were warning signs this was a very important part of the journey one of the things that frightened me so much in my life was how seemingly unpredictable my meltdowns had appeared uh again I write about this in the book that I was so paranoid that I was like the space shuttle Challenger that just out of the out of nowhere would blow up over the sky and the round of it is that space shuttle Challenger which for people don't remember is the Space Shuttle that blew up in January of 1986 that turned out to be an entirely predict predictable disaster had people been paying attention to what the engineers were telling them and so there were lots of yellow lights that predicted that the space shuttle Challenger was going to blow up that day it's just people didn't pay attention and so I had to now identify what my yellow light behaviors were and they had to be plastered right in front of me in a contract that I looked at twice a day every day and whenever those things happened which they did that necessitated an increase in therapy an immediate discussion with somebody it was all about cooling the flames and then there were the green light behaviors which were what you're asking about what are the things that I have to do every single day and these are the things that are going to widen my distress tolerance window that's the sort of figure I include in the book right which is like I have to widen my operating range as as as much as possible um this is something kind of through the the type of therapy I do called dialectical behavioral therapy that's really geared towards making me as emotionally resilient to stressors as possible so it's really through those lenses that I approach the day but just to give you an example of some of the green light behaviors um exercise is important so exercising every day but doing so in a nonforced way this is a very important thing for someone like me exercise has always been important to me but what I had to do was not learn to exercise more but at times learn to exercise less and learn that you know if on Sunday You're trying to get a double workout in but it's ultimately the choice between spending a little bit more time with your kids or getting that second workout in maybe the better thing to do is actually just spend time with the kids and not get the second workout and be okay with that yeah um and be okay with that being the key thing that that's right yeah yeah and and over time that becomes easier and easier and easier um for a long period of time for about a year I did not permit my myself to score in archery meaning in in archery when you do it competitively you actually have scores you keep scores of like exactly where the arrows are hitting and for a year I did not do that so I still practiced archery but I didn't score it in other words I had to take out some of the performance I also for six months did not ever drive the simulator and do archery on the same day I know these things sound kind of crazy but you have to understand for somebody who's recovering in the way that I was I didn't want to have too many of these performance-based things stacking up I also wanted to not look at my phone from the time I woke up for about you know so let's say I woke up around 5:30 in the morning the goal would be to not look at my phone or do any work until my kids left for school at 7:15 so just hang out with my wife have coffee and play with my kids that that was sort of a very important part of resetting anyway there were about I don't know 15 or 16 things on the recovery contract that were part of the Greenlight behaviors and these things had to be done constantly right that was therapy that was checking in with friends once a week who I asked if they would be supporters for me uh that was writing in a journal so there were there were lots of things that I had to do and it took time you know this was a this was a timec consuming process it was as timec consuming as you know exercise was yeah I really appreciate you sharing that again I think what you just said speaks to personalization you had to figure out with your team your your helpers your therapists what was the right approach for you someone else you know not scoring an archery has no relevance to them in their life but it for you that was something that you had to address and I think it it falls on all of us to find what are those things for us I I found it really interesting when reading that chapter in your book Peter when you spoke about the issues in 2017 um I know you didn't write about this stuff in 2019 I heard you talk to Rich about that um and then in 2020 so you'd already been through the you already on this journey yet you said something which I underlined which I found it really interesting at the start of March 2020 when things were kicking off everywhere I let my morning meditation practice go right you let something important go go to you know deal with a a crisis I get that but it's one of those things isn't it that I've learned in my own life there is certain things I don't call them non-negotiables anymore because I feel a non-negotiable brings me back to an old pattern of thinking y y agree so I no longer use that term actually I I feel there's a balance between discipline and compassion and I'm always trying to find The Sweet Spot between those two but I really do appreciate you you sharing that and I think think I think it's going to be helpful for people p i i I think you've written a wonderful book I I don't feel I've even scratched the surface of where I really wanting to go with this conversation but just to finish off Peter for for people who obviously want to learn more they can go to your book but for people who go okay I get it I I get your philosophy it's about getting stuck in earlier and not waiting till it's 2 late or very late before I start addressing things around my health and my longevity I always like to finish the podcast with some sort of actionable take-homes for my audience so for that person who does feel inspired and goes okay right you've convinced me I'm going to get on top of this now I'm 40 years old I'm not going to it's not going to happen to me what happened to my father or my brother or my granddad or whatever I want to take control of my life and my health what would you say to them well if you're if you're really committed I would say get get the data right let's figure out what your you know what your Baseline is according to all of those metrics that matter and and again I we do lay them all out in the book right so you need to know your V2 Max you need to have a dexa scan and know you know what your almi is I mean again if you if you really want to understand these things and yeah it's you're going to have to invest in doing these things I mean whether you're in the UK or in the US no health insurance company is going to pay for that you're going to have to get it on your own and there are less expensive ways to do it there are ways to estimate those things Beyond measuring them via the gold standard but what you want to do is take advantage of the fact that you're 40 right and take advantage of the fact that you have hopefully four or five decades ahead of you on which to compound benefit this is a much different proposition than if you're in the last few years of your life what I call the marginal decade and you realize oh I want to do something about it there's still value in making change at any point but you're going to be able to move the needle less so if you're talking about this through the lens of somebody who's in midlife or even younger what you want to do is say what changes can I make consistently you know I often say I'd much rather someone do seven out of 10 work every single day then do 10 out of 10 work some days and zero out of 10 work other days the the Ping ponging back and forth tends to produce inferior results as far as what to do once you have those results I think the results have to drive it right so if your V2 Max is at the 25th percentile that's an enormous opportunity you have to be doing the type of training that's going to increase V2 Max both increasing your aerobic efficiency your base of aerobic fitness and your Peak if by extension your V2 Max is already at the 80th percentile but your muscle mass and strength are at the 20th percentile then that's where you just need to disproportionately train while you you know do things to maybe maintain your aerobic fitness you know again the list goes on and on if your sleep is really the thing that's suffering then that's where you need to focus and again we kind of lay out how to do that if if you're overnourished and under muscled then you're going to be focusing on strength training protein and calorie reduction and that's probably going to be your biggest Focus to get back onto a Level Playing Field of health so I know that's not a very satisfying answer because it again is an individual answer but unfortunately I think at this level of medicine 3.0 um it's the only way that I can think about talking through these issues if you enjoyed that conversation I think you are really going to enjoy this one about what and when to eat for longevity this is probably the most effective diet that's ever been promoted on the planet this protects our body against Decay disease and the root causes of Aging is not only good for you but will make you live longer

#Daily #Habits #Live #Longer #Happier #Change #Life #Tiny #Step #Time #Peter #Attia

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