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

So the bottom line is that exercise is the number one factor for our

longevity

. You were recently asked. I think it was in the question you guys posted on your show that a guy who plays tennis twice a week and basketball twice a week, is that okay? and I think their response was that it's probably not optimal for the person on the street. I think if they heard that someone played tennis twice a week and basketball twice a week, they'd think, "That guy's doing great!", so I wonder if that's a good

thing

. way to explain your exercise model and why we need

this

broad approach to movement so maybe explain what the centennial is and then I'll come back and your questions are interesting so the centennial decathlon is a model that we use.

To anchor the marginal decade, again the marginal decade, the last decade of your life, then what we want our patients to be able to do is identify again with great specificity physically what they want to be able to do and the physical manifestation of their marginal decade. just describe it as your centennial decathlon, so you might have a lot of goals in that marginal decade, you might know that hopefully you should have some cognitive goals, hopefully you have some emotional goals, relationship goals, um , but when it comes to the physical. goals we want you to be very specific and we start by saying look 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 a few of these that a lot of people would have in mind. your list and there are others that are unique to each individual, so there are some that are on my list that most people wouldn't be interested in, like what would you say I am?

I'm sure most people wouldn't mind you knowing that I want to be able to draw a 50 pound bow. I love archery, so you know, and I currently shoot like a 75-pound bow, but I still want to be able to shoot a 50-pound compound bow. I still want to be able to drive a race car at five percent of the speed I can drive it today. You know, Paul Newman up until a few months before his death he was still driving at

this

speed. You know, almost in his best days. You know, those are really weird esoteric goals for me, but I also have much more generic goals that I think make sense, like I still want to be able to walk up five flights of stairs without interruptions.

I want to be able to walk. going down five flights of stairs, those are different, they require very different types of strength and um, integrity of the musculature, um, I want to be able to get up off the floor, I want to be able to send myself to the floor for 20 minutes and I want to be able to get up under my own power. again. How often do you see an 80-year-old who can do that? It's very, very unusual. You know, I want to be able to lift a child out of a crib. Want to be. able to lift a child off the ground, so there are many other goals I have now.

How can you do that right again? I think if you're listening to this, you're scratching your head a little bit and thinking that they sound really, really easy. What can those objectives be like? You probably haven't spent enough time with people in their 80s and 90s. Those are amazing 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 of those activities, like when it comes to the 110 meter hurdles or the 200 meter dash, you know they are not the fastest, but no one is. faster at doing the 10

thing

s that they do, which encompasses both track and field events and um, they are generally considered the best athletes in the Olympic Games and they train as generalists but with great specificity, yes, so I think we have to apply exactly the same model to ourselves as we prepare for those events.

We have to be great generalists, so we have to have high cardiorespiratory fitness, a broad aerobic base, high levels of strength, a lot of stability, all of these things and we also know that we have to be able to train very specifically to achieve those things, so now let's go. Going back to the question you asked at the beginning, is playing tennis twice a week and basketball twice a week enough to prepare you to be the most robust 85 year old man and I said, believe it or not, I don't think the answer is yes ? Yes, because as wonderful as those sports are, they don't cover all the bases that I just described, they aren't building a very broad aerobic base nor are they building a very high cardiorespiratory peak.

Both are very intermittent. Sports start, stop, start, stop. We're doing 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 and the anaerobic peak, but it's no substitute for having a very broad base and a very high peak. They're not doing much for your strength directly, they're not doing much for your stability, in fact they're challenging your stability, so if a person says I love doing those things, I say that's great, keep doing them if a person says that I want to do it. being able to do those things when you're 80, I mean great, I think it's doable, but you'll need to train to make sure you have the strength, stability and endurance to do those things well, yeah, it's a wonderful framework to look at aging me too.

I like this idea that you specifically have the patience to write down what are 10 things I want to be able to do in my marginal decades. Now I heard you say once that a couple of people will say I want to ski a lot. person in his strength who says he really wants to listen to this ski when he is 95 years old or is skiing a lot a way of saying I want to be independent and be able to enjoy the mountains and nature, whether they do it or not, the point is that you know it. which by putting it means that they can develop a specific program with you and your team to help them accomplish that, oh yeah, completely and the other thing is that these things can be malleable.

I mean, if you asked me this question 10 years ago. I don't know if there might not be a lot of 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 if not, I wouldn't have even done them. list and there would be other activities on the list that aren't as high a priority for me today, so for example, now in my fringe decade, I'd be happy to swim, you know, half a mile. I think that's one of my things. being able to swim half a mile in 20 minutes um, how do you know where you got that from?

Well, you know, swimming used to be really important to me, yeah, so if you'd asked me this a decade ago, you'd probably know it again. I would have wanted to do 10 miles and I would have over-indexed on swimming and I would have been able to swim really long distances, whereas now swimming is much less important to me, so it's mostly about being able to still enjoy the water, yeah, and you know. If now it's swimming half a mile, that would be enough. You know, can I float in water? You know, one of the things I have now is can I get out of the pool on my own?

Without a ladder, could I get on a pool deck and get out of the pool so it's less focused on time in the water, but you're right, um, if you go after skiing and when we have patients that say things like that I mean, I'm not going to discourage anyone from that, but I'm also going to say that that will take an astronomical amount of strength and that you'll have to be a lot stronger in five years than you are now to adequately capture the rate. of glide to where you will be at that moment and by the way, if you fail if you come up short, you will still be able to do a lot of cool things, yes, but let's go for Yes, now I love the focus you bring to something that would otherwise be vague.

I just want to be okay when I'm older. Which means okay so yeah, that's what we really try to get people to do. Understand that no one is not an athlete and you have to think of yourself as an athlete here, no athlete has ever achieved something great without specificity. I mean, pick any athlete who does something today that's exceptional. Do you think they're out there, whether they like it or not? yes, you think Djokovic is like that, yes, it would be great to win Wimbledon. I just played against Santa. I'll just play a little tennis each week.

I mean, there's no chance, yeah, I mean, there's no chance that over and over again we live in a world where sports science has made it very clear what it takes to achieve these physical things, so it's real that There shouldn't be any difference when you think about the activities you want to be able to do in the later years of your life. It's a real irony about sports science because, if I think about humanity as a whole, on the one hand, we're now seeing incredible feats. that we've never seen before, let's say Kip Chougie runs a marathon in under two hours. that was considered physiologically impossible maybe 10 or 15 years ago by certain people, it's not possible for the human body to work on its own or whatever, so it's been proven that that's possible, we're seeing world records left and right and the center going down, we're looking at you. you know Premier League footballers who are playing until they are 40, you know things that we didn't think were possible at the same time, so it seems that the elites are reaping the benefits of the latest sports science and you know that they are pushing new limits in what humans can do.

It feels like the baseline of what the population is capable of is declining and I don't know if you saw this. There was a study recently. I think it was 25 million kids in 28 different countries that basically watched that. Compared to maybe 30 years ago, the average speed that a child took, and this is between the ages of 7 and 17, the average speed that it takes to do a mile has gone down a little bit, it's 90 seconds slower, so There is a certain irony. Not a great point, two things you said, Peter, that I think are really important. Number one is the point you made about if you think you're going to be fine, you probably haven't spent much time around people in their 70s and 80s. or 90 or if you're going to be fine doing nothing and unfortunately in my own life there has been a Stark realization this year.

I won't go into all the details, but my mother, who lives five minutes away from me, on the night of Christmas Day. she had had a fall she was admitted to the hospital she was in the hospital for three weeks there was not enough staff to get her out of bed I would go in and do my own rehab I know how quickly one can lose fitness unfortunately since mom came home three weeks After being in the hospital, she hasn't been the same, she hasn't recovered anywhere near her baseline, so the first point I wanted to address was, "if you haven't seen it, you might not take it so hard." seriously as it should be. taken and then the other point related to that and I kept this page open in your book, it's in the chapter on training 101. but the graph that you pulled from Jason Clifford and Brigham Young University, I spend a lot of time looking at it. graphic I think everyone should see it.

This is figure 11. Figure 11. Yes, this is the decrease in VO2 max. It is absolutely remarkable. The main point I understand from you is that decline is inevitable in your physique. It will happen. You've already said it before. We understand at what rate that's likely to happen and I think it's great that you go down this path if you want to do that at 90 or 80, whatever that point is, you have to take into account the decline and therefore you have to be Now you can do some specific things at 40, a lot of people who listen to this show.

Peter hosts community events in the park every Saturday where you run or walk 5K, right, so I don't know if you're up for a little experiment here. but this graph basically has well, maybe you want to explain the graph because you're probably better than me at doing it, sure, yeah, so the graph shows that I could probably do it from memory, but it shows three three lines, so these lines are placed in uh against the Now I don't remember how much we discussed VO2 max. in the first We don't let me explain this first, so VO2 max means maximum oxygen ventilation, so what is ventilation?

Ventilation rate or oxygen minute ventilation rate. It means how much oxygen you are using at any time, so ventilation rate. It's defined in liters per minute and you and I sitting here right now having this discussion are probably at 0.3.4 liters per minute, maybe 0.5 liters per minute because we're a little animated in the way we speak properly, so there's 500 CC per minute of oxygen consumption if we stood up and walked around this room, that would maybe increase to a liter per minute if we went out there and ran back and forth, you know, that would increase to two and a half liter per minute and eventually, if we continued to force ourselves to exercise at an increasing pace and demand, we would reach a maximum and that can be tested in a laboratory, so it is done in aHigh leads to longer duration. life, I mean, it's very clear, yeah, and by the way, we haven't mentioned it, so it's worth mentioning, everything we've talked about so far regarding VO2 max has been in the context of quality of life, than for the majority.

People matter more than length of life, but it's worth noting that a higher VO2 max is associated with lower all-cause mortality more than any other

health

metric, including not smoking, not having high blood pressure, not having coronary artery disease, not having end-stage renal disease, none of them compare to the damage they cause more than just not being fit, so make sure you take action after watching this video. I've created a free guide to help you develop

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y habits we can all cut back on. -change in the long term, but those changes can become a fundamental part of our life, they often do not and that is why in this free guide I share with you the six crucial steps that you must follow and that are really effective if you want to achieve it .

Free guide right now, all you have to do is click the link in the description box below for the risk index association of being in the top two percent of VO2 max compared to the bottom 25 be a risk ratio of more than five, it's just that it's an it's an amazing yes, it's almost as amazing when you consider that having high resistance, high resistance to low resistance is almost as powerful, it's a risk ratio of more than three and for people who don't know.Hazard ratio Pizza explained it in depth in our first conversation, yeah, yeah, very good, so let's talk about these things.

Why is strength so important? Why is stability so important? Instability by the way, there's a whole chapter on it because it's the strangest concept. Of those four, so it justifies the exercise component, there is a section of this book that consists of three chapters, but stability itself is one of them, stability is basically the ability to transmit force from the body to the world. outside and vice versa stably and without injuries. would be the easiest way to explain that, so every time you take a step you are transmitting a force to the ground, that is what propels you forward, but a force is transmitted in the equal and opposite direction towards you, so what? that?

It prevents you from hurting your knee, hip and back. It is stability. What allows you to do that efficiently is stability. In general, when an older person falls it is due to a lack of strength and stability. Stability is, for example, what allows the foot to maintain balance. If you think about it and look in the mirror, if you're doing an exercise standing on one leg, yeah, let's say you're doing a one-legged RDL or something like that. , you'll notice that foot moves like crazy. to try to preserve balance, a romanian audio deathlet for anyone not familiar with that, yes, but look, stand in front of a mirror and stand on one leg and look at your foot.

You look at what you need to do and we think of that as balance, but balance. it's kind of like the reading state for stability, yes most people have probably heard of different types of muscle fibers, fast twitch muscle fibers and slow twitch muscle fibers, well the fast twitch muscle fiber It's type 2, muscle fibers are the muscle fibers that give us Slow twitch muscle fibers are the ones that power and I'm oversimplifying a little bit, but they're the ones that give us the most resistance, so you can have strength in both fibers. , but the explosive power comes in the type 2 muscle fiber, well, that's the hallmark of aging, it's the atrophy of that type 2 muscle fiber, so hold on, please.

When we hear about fast twitch, some of us will say yes, if I want to be a 100 meter sprinter, that's what I need. What is the relevance of that when I am 80 years old? Because when you're 80 years old, if you lose your balance a little bit and let's say you're stepping off a sidewalk and you lose your balance, you need to do it. being able to react with enormous force and those are those fast twitch fibers, the term fast twitch and slow twitch is unfortunately a little misleading, although it is completely true that fast twitch fibers contract faster, which really means and The real reason we use the terminology is that they are quick to fatigue because they are much more powerful, so a better way to think about it is that you have high power fibers that fatigue quickly and you have lower power fibers that fatigue very slowly and Unfortunately as we age we lose the first and most of the injuries.

What we see in people as they age is a direct result of the atrophy of that powerful muscle fiber that fatigues quickly. Now, if you train it, you can keep it. Now you will never keep it. 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 year old can still have fast twitch muscle fibers. of a 60 year old person and that is what we want to have, we want to know that we still maintain some power in those muscle fibers and that is why, for example, lifting heavy weights is essential for everyone at all ages, whether men or women.

Again, one of the big misconceptions is that women don't need to lift weights. You know, that's completely wrong. One of the misconceptions is that you know that as you get older you shouldn't lift weights. I mean, this is a completely misconception, so strength training is imperative for people as they age and not only does it have a huge impact on bone mineral density, but it also has this huge impact on these muscle fibers. type 2, we were talking about fast twitch and sprinters. I just want to clarify that when you lift weights, is it necessary to do it with speed to really help that fast twitch fiber or just lifting a heavy weight slowly also counts as a stimulus for that particular thing, it still is, you don't need to lift it quickly , so it really comes down to weight, so you need to lift a heavy enough weight that the type 2 muscle fiber is recruited and if the weight is not heavy enough, the muscle will simply recruit the twitch fibers slow to get the job done, yeah, step back for a moment and think about a lot of the centenarians we see being interviewed and of course that's not a scientific study.

These are just observations of humans in blue zones or wherever they may be. What strikes me is very interesting is that very few of them were trying to work on their

longevity

, as far as I can tell, it doesn't mean we shouldn't be. It's also pretty obvious that most of those people live in environments where a lot of the things you write about are automatically covered. Let's say I don't know a farmer in Sardinia who still herds goats in his 80s. Well it's like uphill walking a lot VO2 max probably lifting things I just think it's always good to get away and go well these guys weren't measuring all the metrics they weren't looking at these decline graphs Sorry and I'm wondering how you feel about this It's that because of the way many of us live now, we need these Frameworks to help us achieve what these guys are doing naturally.

Yes, would you see it differently? No. I see it exactly that way. Do you remember? uh, in, like the original Spider. -Man Story You have Peter Parker when you know when his uncle Ben was shot yeah and um you know right before his uncle tells him something which is you know Peter with great power comes great responsibility and I always. I have that in the back of my mind when I think about modernity. Do I like the fact that it's 2023 right now? Or is there any reason I would want to go back to 1923 or 1823 if you gave me the answer in a time machine?

It's zero chance, there's no chance I'd want to go back to 1923, 1823 or 1723. In other words, I completely buy the beauty of the modern world we live in; It's not perfect, but it's better than the world of 100 years ago, 200 years ago. ago and 300 years, but it has a cost like everything and we have to be very aware of that cost and by the way, I think exercise and nutrition are probably the two best examples of where we pay that price, so you know, we spend Hundreds of millions of years evolving depending on which form of us you're considering, but even if you consider just Homo sapiens, think about the last few hundred thousand years of evolution, which really gave us our superpower to LeapFrog ahead of all of these. other species was our brain and what allowed us to have a brain that demanded so much energy was the ability to store energy.

Yes, in some ways the human superpower from an energy point of view is the ability to store energy. We are very efficient in energy storage. It served us incredibly well until relatively recently, when energy became so abundant, of course, in the form of food, that the superpower became a detriment and now most people in the developed world are overnourished and we are in the wrong side of the energy curve, yes. That means we should all aspire to be hunter-gatherers again, where we don't know where our next meal will come from. No, it just means that we have to understand that with this great privilege comes responsibility.

The same goes for movement. Our ancestors did not deliberately exercise if they saw that there were things like gyms and treadmills, they would not understand what we were doing, but this is all a construct that we have had to create, yes, to compensate for the fact that the modern world has removed the need for all movement from our lives, so we have to go further, so maybe if you know you're listening to this and you're a person who doesn't like to exercise, that's okay, but understand. that living in the modern world comes with a lot of responsibility for yourself, yes, and even though you know that your ancestors from five generations ago didn't exercise, they didn't need it because of what they were doing, yes, and I also want to say that I love it . that line of thinking because it also means that I think yes, we should take as much responsibility as possible within our means, within our you know what is possible in our environments, but I often say to patients if your great-grandparents we are here today in this food environment, you know, we would probably find that 78 of them would also be overweight and obese, it's not a moral failing, no, not at all, it was your superpower in a different environment, now it's your Achilles heel, um, so definitely worth considering and even this laziness to exercise we have always been a little lazy we have always tried to conserve energy I I I one of my dreams is to go to a tribe I would say it's a dream thought experiment with a treadmill I wonder what They'd think you're on a treadmill for an hour you're not even going anywhere what you're actually doing is ridiculous and it's already been done I mean, anthropologists today there are still a handful of hunter-gatherer tribes out there and everything I've read says they're in Prime energy conservation mode, so when they're not hunting, gathering, or moving with deliberate purpose, they're conserving energy as much as possible, they don't go into, you know, In fact, I think Herman Ponzer was going to write about it and he writes about it, yes, and the total body energy expenditure is quite low, yes, it's really fascinating, so let's go back to these four pillars, then okay, if we want.

To be well in our marginal decades and we are thinking about exercise, we must think about four components: VO2, maximum strength, zone 2, cardio and stability, we have touched on the VO2 mats, we have touched on strength before we move on from strength. We're talking about lifting heavy weights, so I guess I have two questions: One is what counts as strength, right? The reason I asked that question is because let's say you're a runner, and I personally think running is fantastic, it's a very innate human movement, it's you. 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 hills that's a form of strength training for your legs so if you're a runner and yes this is lower body not upper body, if you do hill reps regularly that qualifies as strength training, probably not because it's still a high enough rep number to not hit the type 2 muscle fibers, okay, as evidence and, by the way, even when I'm walking uphill with a hundred pounds on my back at a 15 degree.

I'm still doing so many reps that I'm primarily fatiguing my type 1 fibers, okay, though be you the one who movesyour body weight against gravity, which is a form of weight, yeah, it doesn't meet the threshold for working on that particular tattoo fiber, so we're going to need one with 70 or 80 coming off a sidewalk, so that a better example would be doing a box step with weight in your hands, you know what they like if it's getting a box, setting up a box, going up and down, up and down, holding the weight in your hands and if you did it like that way that you could literally, you know, we normally talk. about doing these sets until you have one or two reps in reserve so you don't have to fail when you're lifting, but you want to continue until you can only do one or two more reps and that would be failure and if you're loaded to the point where you're doing eight to twenty reps but you meet that criteria, one or two reps in Reserve at most, by definition, now you're recruiting type 2 muscle fibers, okay?

You've fatigued throughout type one into your type two, so as a runner you'll appreciate the difference and what that burn feels like compared to the burn of running repeated hills again, there are many benefits to running Hillary. um and you're testing your VO2 max and you're doing a bunch of other things um and by the way, as a runner you're going to benefit from the strength that comes from those box climbs, okay, it's fascinating, so that was a component of the hill. reps don't count, you're looking at something that's just one or two away from your max, which I think is very helpful, very, very specific for people and, again, in terms of making this accessible to people, it's a painting that you know relatively. you know most people have access to that right yeah 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 anywhere .

It doesn't have to be a super fancy gym, you know, carrying weights, doing what's called a farmer's carry, such an important form of activity, so much for grappling, that most people will find it when they do it. initially, and we have standards for our patients when it comes to these types of exercises, whether it's box step UPS, um, if farmers carry, you know, for example, for a woman, we want her ultimately, uh, and we index this per decade, but we say a 40-year-old woman should be able to carry 75 of it. body weight in her hands for one minute, so if she weighs one hundred pounds she should be able to carry 75 37 and a half pounds in each hand for one minute and if she can do it, if she can, then what does that mean? ?

We're very confident that when she's in her twilight years she'll have the strength to open a jar, for example, to do the kinds of things that we think people really care about. Yeah, I love that it's really specific because any woman who's listening to the show right now can go and check it out for themselves and see what I can wear now if they can't. Say they're going well, this sounds great, oh wow, I can only do 20 or 30 percent or I can only hold it for 20 seconds and then my grip fades, yeah, so what's the advice?

So it means lowering the weight, so let's say you go to the middle of your body. weight until you can reach a minute, find a weight you can reach in a minute and then slowly advance the weight, that's brilliant, really practical and for a man it's your body weight for a minute, so at what age again in your fifth decade, between 40 and 50 years old. So, for example, if a man weighs 180 pounds, he should be able to hold 90 pounds in each hand and walk for one minute. Yeah, I love that and, again, a lot of people won't be able to. to do that from the beginning, okay, drop it, go to 70 of your body weight, go to 50 of your body weight, um, it's interesting that a lot of people stop strength training, they think they may have never done it.

Like Kids can be intimidated by gyms, they might not know what to do and think, ah man, I can't afford a personal trainer, I don't know what I'm doing, farmers carry that, it's something you already know I guess. . You have to be aware that you're not sticking your head out right, that you have decent alignment, and yes, you probably need some body awareness, but it's a pretty accessible thing that people can try for themselves. I think so, for sure. We have, we have, um, I don't remember if we included farmers in the video in the book, but there are a series of videos that we made to accompany the book.

It's on their website, right, yeah, yeah, um. so that's us, there are probably less than the program notes, yes there are at least half a dozen exercises, including step by step, where we show the correct form because you are right, you can cheat, you can do these things incorrectly, there is many There are many ways to do this and we always have people who start these things with just body weight, for example, on the step up, you know before we move on to, anyway,

stay

ing in strength, let's talk about strength grip and the strength of the feet, the extremities of our body, why are they?

It's very important, maybe there's a lot of data on grip strength, yes, but what's fascinating to me is that you're going to explain to me the data, I'm sure, on grip strength, but that might tell someone that I need to strengthen my grip, so I'm going to do it. buy, buy those little grabby scripts and get really strong reviews, which I'm not entirely convinced is going to do what we want, so maybe expand on that if you can, yeah, so I think the same reason why that VO2 max is such a notable indicator of lifespan and health, that's why grip strength always seems to be a notable indicator for both as well and it all comes down to what indicators are or what I like describe as integral so that you already know how a hemoglobin works.

The A1c, at least in theory, is supposed to be an integral or sum of what your blood glucose has been like over the past three months. Similarly, a very high VO2 max is an integral of training very hard over a long period of time, yes, if you took an unfit person and said: I want you to train very hard for a week, they are not going to have a VO2 max high in a week; In fact, if you take a person in the bottom fifth percentile and have them exercise for three months, we're not going to get to the top fifth percentile, which is why you can say that a person in the top five percent of VO2 max It has years of training, that's what it tells you, so it's a very good predictor of life expectancy because it reflects a lot more than we can.

Have you ever walked out of a quiz tell me how much exercise you do a week and how strenuous it is who cares how all those entries are reflected and it can't be hidden, it can't be masked, it can't be fooled, yes the same is true , with grip strength grip strength is an integral part of

overall

strength, you can't be very strong without having a strong grip, so I mean, 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 in a hotel that I was setting up yesterday and sometimes I carry liquid chalk with me because you know, if you're in a gym and they don't like you using chalk, you have this liquid chalk and I forgot. to bring my liquid chalk so yesterday I had to deadlift without chalk and it's just a stark reminder of how I limit my grip when I'm deadlifting, in other words like I was failing because I couldn't even hold the bar anymore .

In fact, I ended up dropping the bar at some point, not because my glutes, my quads, and my legs were limited by my grip, and you start to realize that a lot of what I do in the gym is driven by my strength. grip. Yes, when I'm doing pull-ups, if my grip fails, I'm failing and that's why farmers carry, of course, it's such a good functional exercise, that's right, yes, you're using your grip so often when you're strength training, etc It is true that it is easy to measure and that also applies to VO2 max. It is objective, scientifically measurable, reproducible, you can measure it here in London, you can measure it in San Francisco, you can measure it in Delhi, it doesn't matter where you are.

You can always measure the same thing, it's true with grip strength, leg extension, chest press. I mean, these are the things they typically measure, but you know you'll always see studies talk about grip strength and I agree with you. completely, it's a little misleading, yeah, because people think it's cool, I just need to go get a little juicer and it's like no, definitely, don't get a little juicer, pick up heavy things and walk, yeah, there's something about that , the extremes. Isn't that how we interact and transport things, but our feet, how we interact and that is that these are the hands and the feet are the transmission of the Force to the outside?

Yes, I was going to say bias, but yes, I was. trying to be aware of my own biases. I have personally been wearing minimalist shoes for over 10 years. They have been transformative for me. I have recommended them to many patients over the years, not all, but many of them, and I have heard and seen so many improvements again, you have to be careful. I'm not talking about going from wearing padded shoes, you're in Thailite to suddenly trying to run marathons with minimal problems, no, let's be logical, let's be rational about this. but I'm wondering what your perspective on foot strength is, how it relates to what you just said about grip strength, and potentially where barefoot and minimalist shoes might fit into this part of the conversation.

Yeah, I mean, I have the luxury of doing it because I work out. At home I exercise barefoot, so I really enjoy being barefoot as much as possible and I think, look, feet are very similar to hands, in terms of musculature, what I think most people would appreciate is that we have a lot of more skill. with our hands than with our feet and, um, part of that is the fact that our hands are never really restricted like our feet are, when we wear tight shoes constantly, in other words, it's not just about being in a shoe minimalist versus non-minimalist is like having your toes squeezed together, yeah, you know, 12 hours a day, which creates difficulty using your foot the way it should be used for people who have children. look at your children's feet, yeah, you see what's going on, yeah, so anyway, on the way to saying, I completely agree.

I think the shoe industry has probably gotten to a place where we're not. achieve healthy feet and many people, including myself, have had to spend a lot of time repairing the damage caused by wearing shoes too often and shoes that are too tight, and you know, it's interesting that a study was done at the University of Liverpool a couple of ago of years and To be fair, the study was done in fever, Beth, which must not be completely transparent, everyone wanted the fans of this show, um, and I was making it clear that I was buying them with my own money for seven years before they started sponsoring.

That said, the program showed that adults who wore these minimalist shoes for four to six months just for regular activities went to work, went to the stores, went for walks, not to run or not to go to the gym, just to exercise . Continuing with your day, I think as I remember it, your foot strength increased by over 60 percent, which I found notable because you're not actively trying to exercise your feet, you're just wearing something that allows your feet to be seen. affected. having to work harder than when they are fully cushioned, yes, which is pretty incredible, just taking a short break to appreciate the Vivo barefoot shoes.

I have been a big fan of Vivo barefoot shoes for over 10 years. Before they started supporting my podcast, they are the only shoes I wear, so they have really had a big impact on my own life and the lives of many of my patients. You see when people start wearing minimalist shoes like alive, you can see improvements in things. such as back pain hip pain knee pain foot pain even things like plantar fasciitis can often improve and scientific research shows us that just wearing vivo for about four months improves foot strength by over 60 which It's absolutely incredible.

What I don't realize about these shoes is how flexible they are, allowing your feet to do what they naturally want to do instead of the shoe dictating your foot movements. Vivo Barefoot is giving my audience a unique 15 off code when you place your first order and they make it super easy for you to try them out. They offer a 100-day trial for new customers, so if you don't like them, simply return them for a full refund. I'm a big fan. I really hope you take advantage of this offer to get your 15 discount codes. All you need to do is go to Vivo barefoot.com, click on vivo more or click the link in the description box below, so I just wanted to do that before we continue.

Strength only touches women, there are some unique pressures on women, especially after menopause,so I just wanted to talk about that when we talk about strength training, yes it is very important for both men and women, but are there particular reasons and your point of view? Why women need to pay special attention partly, I mean, there are several, but partly I think that, on average, women come, for example, to our practice or, you know, in middle adulthood, in middle age, they've done less strength training than men, um of course, we use nomograms that are sex-specific, so when we look at muscle mass metrics we use something called appendicular lean mass index and fat-free mass index , so they will be normalized by age and gender, but you know.

Women often come in having done less strength training, so they will have less muscle mass. That's a problem, yeah, yeah, sure strength and muscle mass are positively associated with life expectancy and health for men and women alike, and um, there's a big step. once you're at the 75th percentile, in other words, top 25 compared to bottom 25 for muscle mass is a pretty significant difference, in terms of all-cause mortality risk, okay, so let's imagine see scenarios here, teenager or there is a father who listens and is worried about his daughter, let's say maybe also about his son, who is a teenager.

We've talked all about the decline that occurs between 30 and 40. Are there things we can and should do with our children? with teenagers to further isolate them, oh, if you're from this absolute decline and I'm glad you brought that up because, um, bone mineral density has a strong genetic component, um, however, you reach your genetic ceiling or your genetic potential. when you're in your early 20s and So if you think about the implications of that, it means that people who don't do the types of activities and, again, strength training is the most important activity on the list, if you don't lift weights when you were a teenager when you were 20 years old.

We are not going to reach your genetic limit and everyone, both men and women, is in a state of decreased bone mineral density from their mid to late 20s onwards for the rest of their life, so if it is before that , if it is in the correct list. Now, and you are a teenager or if you are a parent, we should do everything we can to encourage our children or yourself, if you are that teenager, to lift heavy weights until at least 22-23, much further, but beyond , but there is this beautiful window in which you can capture your genetic potential, okay and again everyone, men and women, will start to decline from the age of 20 onwards.

Women have a much more precipitous decline in menopause if they do not take hormone replacement therapy, so estrogen. It is the most important hormone in bone health for both men and women and women lose their estrogen precipitously around age 50 if they do not receive HRT, so in that sense women are more susceptible and it is not uncommon to see women in The menopause transition that they haven't been lifting weights even if they've been very fit and they've been exercising, they show up with osteopenia, uh, wow, and I mean, we see this way too often, two things to comment on, one is that It makes me feel better about some of the disagreements my wife and I often have if they are if a new delivery of kettlebells comes home and I have them lying around and the kids pick them up and play with them and my wife says no. , no, put it down you'll get hurt, I say, hey, leave it, let them pick it up, sure, there are injuries to consider, you have to be safe, but I think you know what kind of let them do it, it's funny you say that.

I mean, both of my kids, one who just turned six and the other eight, really got interested in coming to the gym with me last year and I just started doing kettlebell lifts, so it's deadlifting. basically with a kettlebell, so they were standing on a kettlebell and at first I just had them do it with the lighter kettlebells and they were getting really upset and really wanted to start lifting heavy things, so I said, " It's okay, guys, with the condition." that you can listen to me and you can do this correctly and it actually turned out to be quite challenging to instruct a five and six year old to deadlift because I can't instruct him the way I would instruct you, yes, I can.

Not talking to him about intra-abdominal pressure and thoracic extension and stuff, it has to be a lot simpler, so the first thing I realized when I saw him pick it up is that he was doing it incorrectly and I was surprised to think that a child would always do it. he picked something up correctly but he didn't do it he was using his back and not his legs and I thought why is he doing that and I realized oh immediately like his arms are bent if you don't have tension in your arms if you don't you don't have a deep tension in your arms, you can't use your legs if you have any tension laxity in your upper body and he was leaning so far that he seemed to grab the thing so close and then try to lift it with his back, so anyway it was a great exercise for me to learn how to give him the right cues, but then see how perfectly they can lift things, um and now it's fine, so he just comes to the gym and all he wants to do is lift that. kettlebell up and down up and down up and I want to see he just turned six in a couple of weeks.

I love him, yes I love him and obviously he wants to do what daddy does and lift things. I want to do that too so we can. potentially take advantage of that, yes, but the point is that this is very important for teenagers and again, maybe you mentioned something earlier that I think is a worrying and disturbing statistic, and you know that for any period of time that I can. I don't remember 30 years, I think you said there was a 90 92 loss in a mile time, you know, unfortunately, I'm sure there's a comparable statistic for strength loss as well, so yeah, basically with kids and teens. we want to encourage this early.

Now, of course, the same goes for fitness; In other words, you like it. I feel very lucky to know that even though I don't train at a fraction of the level I used to, I think that's the reason I'm able to maintain a relatively high level. high level of fitness is that I maintained an absurd level of fitness when I was a teenager and 20 years old, in other words I reached a genetic ceiling that I think makes it easier for me to

stay

in shape from time to time, that shouldn't mean that no one who reaches 50 who is not in shape should be discouraged in many ways they have more potential they have the potential to be taller than before I no, I will never be as tall as before um but I will I will probably be taller than that person due to the fact that I had that ability so

young

, so you know your point again: if you're listening to this and you're a parent or a teenager, you really want to make sure that your kids are in shape, yeah, when I think about the pizza at your work and when I think the things you're talking about outlast a lot of what you ask or I guess suggest people consider doing in their lives, it requires them to make some pretty significant changes.

At times throughout my career as a doctor, I have changed my perspective on what really makes a patient change. I used to believe that all you needed was knowledge, knowledge is power and I've realized that I don't think that's the whole story, even with the knowledge I see there is a lot of knowledge available and podcasts books yes knowledge were the answer, we wouldn't have a healthcare crisis, so my question to you is, based on your experience, what are the common obstacles that you face? find for people who are trying to make changes, I think it depends on the changes, but if so, leave that nuance aside for the moment.

I think that in some cases the impediment to change is just inertia. I mean, sometimes it's hard to say, you know. this is the way I live my life these are my habits I want to create a new set of habits that requires a kind of willingness to do something different that for some people they don't want to break a habit so I'll give you an example um because I think that You realize that that doesn't sound very clear um if you tell a person um look you have to go to bed an hour earlier and it would be great if you didn't fall Sleep on the couch watching TV because that hour of sleep that you're sleeping on the couch then you have than waking up and going to bed like this, that is poor quality, sleeping well, the impediment to changing is not that they don't do it.

I understand, like you said, that sleep is important, but it's just that they have a real habit of sitting on the couch and watching TV after you know how to relax and now you're basically saying, well, you're going to come up with a new way to relax. so it's the introduction of, you know, we're going to make a change, but it actually requires several changes and I think that underlies a lot of things. I also think there are certain things that people have to do that are not so pleasant. Initially, for a person who has never exercised, I think it is actually quite intimidating and initially unpleasant to exercise and you can tell them until you are blue in the face that once you get over the initial challenge of this, it will actually feel quite a bit.

Well, actually you're going to appreciate the fact that it's not only beneficial for you in the long term, but also in the short term, but sometimes you have to give a little faith to achieve it, um, I think. When it comes to changing behaviors, for example, like food, 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 know to stop eat this way and start eating. This way it's not as simple as saying okay, your pantry needs to change and the types of places you go to lunch need to change because you know you want the changes to require less willpower, yes, and more automated behavior. , yeah, so no I don't think I'm being very eloquent when I say this, but I guess what I'm trying to say is that it's usually not one change, yes, it's usually multiple changes that need to be configured for the Interest behavior to be more automatic, yes, I would say that echoes a lot of my own experience.

I guess what I've been thinking with patients very similar to you. I think all behaviors are therefore a reason why they play a role in our lives and I think often trying to change the behavior without understanding what was driving it, so is the sugar you crave at 9:00 p. m. on the couch, really physically hungry or is it emotional hunger, you know, you've had a shitty day, you've had a fight with your partner and that little bit of sugar will help you because if so, you may need a strategy different. Are you feeling lonely and instead of sugar maybe you want a phone call? your friends are stress, maybe you want a relaxing bath instead of that sugar, whatever it is, and I would say that's one of the key things that I've learned throughout my career, yes, you can change behavior without address that. but it tends to be short-lived classically New Year's New You know, I'm spinning four times a week every week all year long, don't you do it for two weeks when your motivation is high and suddenly you've had? that bad day at work and you need to pick up the kids and whatever, you know, that's too hard, so it's not something that you spend time in your practice trying to understand because look, the behaviors are great.

I want to talk more about these behaviors. that we want people to do, but often it's not the behavior, but the impediment to that behavior that I find I spend a lot of time with patients. I think it happens to us too and I think that's the, I think that's the biggest challenge and certainly within a year of being in our practice, there isn't a patient that doesn't know what they should be doing right, that's , you know, there's not much of a mystery, it could be a mystery when it comes in, there may actually be some confusion about whether you know the optimal strategy around exercise or whatever, you know, one of the things that we try to remind the people.

I just think about it with the example you gave, it is trying not to have too much back. backwards it fails, yes, of course, then the example you gave about it, for two weeks you are doing your four spinning classes a week and everything is going well and then you have that bad day. I think a lot of people get into a Negative Spiral when they beat themselves up for that bad day and feel ashamed for missing their workout, something that they said they set out to, you know, set out to do and that shame becomes in the most dominant emotion as they are. getting ready to have the next workout and it becomes easier to miss that next workout and instead what I think you want to try is to say look, you have that bad food that you said you weren't going to eat, you missed that workout, you do something. that's a little out of your way, um, just give yourself a total pass without judging yourself and justsay yes, it's very difficult, like this is easy, you would have done it last year or the year before or the year before, but do it right. the next one just make sure the next meal is right, make sure the next workout is done um and even I find this to be important to me.

I mean, I and I tend to know that people would look at me and assume that I'm some kind of beacon of willpower. um but it's not always true and I still have to be very impartial and remind myself when I'm wrong that it's okay and let's try not to be wrong tomorrow is something new that you've had to learn in general absolutely. Um, it's become more relevant as I've gotten older, so, you know, I think when I was

young

er and even more selfish there were never any reasons to stray, but now with a family with other responsibilities there are plenty of reasons to stray.

And sometimes I find those better uses of my time and as a result of that, I sometimes fight myself thinking about what happened to you, yeah, look how much you're slacking off and you know what you're talking about, but but. Yes, I think I am much more compassionate with myself today than I used to be. Yeah, sure, I mean, I would berate myself a lot in the past if I said I was going to do something and I didn't. There were many things. of negative self-talk and you realize that it is never as helpful if shame or guilt is the underlying emotion.

I just don't think it's sustainable in the long term, it's always going to surprise you at some points, certainly that's what I felt like the way that that's completely different, so going back to what the impediments to behavior change are, I find that there are another phenotype that I see in my practice, which is, um, another manifestation of trauma, which is basically the individual. who is completely incapable of taking care of himself or putting himself ahead of others, yes, I see this phenotype most commonly in women and I see this frequently, you know, a mother who knows that she does a lot of heroic things, so she probably works very hard . at a job, she probably puts the needs of her husband and children before her own, but she does it to the detriment of her own health, yes, and she lets you know that you know that's the case, she somehow understands that her health is suffering , but she almost feels like it's her place to suffer and she can't make that exception and you know you're going to say it feels like you have to carve out an hour a day to do these things and she's like yeah, I know. "I should, but and then there are a series of excuses, but you realize that deep down what's happening is like there's a form of self-punishment and I'm not saying that's true for all mothers who are working breaking the butt, but me." I'm just saying in the examples that I've seen in my practice that I really attribute this to sort of maladaptive behavior around trauma and um and that's another example of where you know, I would describe it as sort of an emotional health failure which is falling into cascading into physical health failure, yes, I would say that one of the things that I have learned that influences what you just said about this trauma is the pace that many people have today.

I would call them low-grade addictions, whether it's sugar or social media, online shopping or online browsing, whatever gets in the way of other behaviors, because there are a lot of behaviors that people could adopt to get better. what someone said: longevity, but I think this is a really important piece. Do you know why people can? I don't do those behaviors, why do many people perceive themselves as not having time? And I mean, I really like Gable's companions, um definition of addiction, which is again, if I destroy it a little, please forgive me, but something has these three components, uh, anything.

Behavior or substance that you crave, that relieves pain or gives you pleasure, and that you cannot stop doing or give up despite the negative consequences, through that lens of looking at addiction, I would say. Many of us, most of us We all have some level of addiction and I'm interested, do you think it is a relevant area to address with your patients? Do you find these low-grade addictions getting in your way? potentially more useful changes when it comes to your longevity, yes, but I'd take an even further step back and say forget about the impact of these addictions on your ability to exercise, eat, or sleep properly.

I would say just talk about the impact. of those addictions in their relationships um and and I think that's what's interesting about trauma is that usually at some level underpins some of these behaviors and by the way, I think that term is so loaded and people think that trauma has to be big. T trauma, but very little, T trauma can be just as impactful, um, but not dealing with those things and not understanding that most of those things produce really wonderful adaptations, but as a collateral, sometimes they have maladaptive behaviors, yeah , and they can't deal. with those things can have the impact on the physical side that we talked about right, generally it will manifest itself in the form of not taking care of yourself through those behaviors, those positive behaviors, but it can also be quite detrimental to your interpersonal relationships and and I think that if your interpersonal relationships are compromised, your quality of life is compromised, your happiness is compromised, your joy is compromised and, honestly, I think that's just as problematic, so to your question, I think the way to approach that with patients is probably to find out where they feel the most discomfort, yes, and I think that varies between individuals, so I think there are some people who feel that discomfort more in relation to behaviors that they are not performing correctly, ie.

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 way they're going to deal with that is going to come through destruction or damage in their relationships with their spouse. , your kids, your friends, co-workers, that's when you really delve into this area and I know that you yourself have been on a personal journey 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, you don't know, being physically healthier, of course, also helps us with our emotional health, but I feel like the emotional health part does drive us. to improve. -Be careful, yes, it helps your relationships, but you know there is a lot of research now that shows that I have to be very careful when saying this because I don't blame people at all, but now there are strong associations between people who hold on to relationships. negative emotions holding on to anger and resentment that they can't forgive and the risk of autoimmune diseases and again I don't blame people, there are associations in the literature if I look at my own practice, my non-nhs The practice was filled in large measure of people with autoimmune diseases.

A lot of women. I saw these types of personality traits a lot. I don't know if you're familiar with Fred Luskin's work at Stanford on forgiveness and the ability to forgive in blood pressure. Really very interesting and I think I've followed you for years, Peter, so you strike me as someone with whom you've openly shared things that you measure in your own life for many years. I often think of that phrase that you don't know everything. What we measure matters and not everything that matters can be measured exactly, so yes, we can measure key metrics and we talked about some of them.

The first time you came to my program, but there were other types of non-measurable elements that I find more and more have an impact on health. I'm thinking specifically of a patient. I think she was 48 years old. She had slightly elevated blood pressure. I don't remember the exact numbers, but I'm guessing she was in the region of 135 to 140 plus. 90 something like that and for six months we tried to make changes with the lysashi transformed her diet, she started exercising, you know, started prioritizing her sleep, yeah, I couldn't get her to move, I couldn't help her achieve it. to give in and we mentioned it correctly we did 24 hour monitoring and I thought what am I missing here now of course some people are going to resist maybe she needs pharmacies of course but talking to her I felt like she was holding on to a lot anger and it turns out that as I got to know him more, she actually was, she separated from her ex-husband who had cheated on her and she couldn't let him go, she just couldn't. letting go and we talked a little bit about forgiveness and the importance of doing that and letting go and I won't go into everything that we did, but essentially over the next few months she basically learned the skill of forgiveness that she managed to let go. the anger she felt and her blood pressure normalized now, that's an N equals one.

I am aware of that, but I share it with you because these things really teach me that there are all kinds of contributions in a human being that manifest in their physicality. health and I didn't learn those things in medical school, I just learned them just by observing and then you go to the literature and I see that there is research to support it, now we have the same quality of evidence for that. like we might do with a particular form of exercise to lower blood pressure, probably not, but on an individual level, when I have someone in front of me, I always try to think about what inputs here I can manipulate, what I might be missing here. and you're someone I respect incredibly, so this feels like the softer side of Medicine, but I think it's just as important as the harder side and I think I love your thoughts and your perspective on areas like that.

Oh, I, I would completely agree with that. uh in all respects correct meaning that I think that matters absolutely I think it's very difficult to quantify, if not impossible absolutely, um for me, the most important question is um, you know how to teach it well, so how did you get it? That patient, uh, who I think most people wouldn't blame her if she basically said, I'm going to carry this, you know, an ax to grind for the rest of my life. Most people would say she understood, yes, she understands. So how did you work? with her to, firstly, convince her that it was worth trying to forgive her ex and then, secondly, how did he actually do that?

Yes, first of all, I believe in her informed consent, so I explain the situation to her. I explained to her the risks of not treating that blood pressure in terms of her long-term health and explained what the options were. I also established a very good relationship with her. I got to know her. This is one of the most difficult abuses these days. To be fair, but certainly a few years ago there was still that continuity in primary care where you were in the NHS here, where you knew someone, you knew their family, you could really see who was in their lives in a way that you don't always get. with hospital medicine, so I built a very good relationship with her, she trusted me, so I don't go there with every patient.

I just have an idea of ​​what I am so you know when the time was right in a consultation when I felt like she was open to it. I told her: listen, she has done an incredible job with all the changes she made to her lifestyle. I would have expected to see some change here, not always, but generally my feeling is that I chose. I mentioned a couple of things of mine that I think maybe Play Hair would do well if I went over some of them with you. Are you interested? I approached her and the first time I brought it up, you know, brick wall, she wasn't having it. go there, but I would like to see patients regularly, even if it's just 10 minutes.

I often get them every few weeks. I like to follow up with them and talk to them and it got to the point where she was open. She goes. I told. Look, we can put her on her medication or we can try this because I think this can help her blood pressure, but frankly, I think it will also help in many other aspects of her life. If she holds on to this, I understand and I will explain it to her. her that forgiveness would not be for her ex-husband, it would be for her and I don't remember the exact exercise.

I think I wrote this in my third book, but it was an exercise in forgiveness, just a four-step process of asking. her, do you know exactly what emotion she was holding on to, what benefit it gave her, there is a chance that you can see it from your ex-husband's perspective, do you know what might have been going through her mind and are you willing? carry this for the rest of your life because essentially and I don't remember the language I used I said actually that means your husband still has power over you today your ex husband an act that he did still affects you in your day today so again , I don't want to, I don't want to derail the whole podcast about this case, but it wasn't just a quick fix, it took time, it took trust, it took him trying a little bit and coming back.

I think our offers refer to psychotherapists. I don't think she wanted to, she built trust with me, but the point is, yes, it was difficult, but I think that not only helped with her blood pressure, but she's going to get better as well. dividends in multiple aspects of her life, emotionally and physically, for years to come. I am convinced of this and I agree with you. I think there's a subtle point there, which is that I think it's abetter health outcome than just addressing it pharmacologically, so if I had I would have just given him an Ace inhibitor or an ARB, it would have fixed his blood pressure, but it probably wouldn't have fixed the underlying sympathetic tone, the hypercortisolemia that was still going to have consequences negative for health and I have done it with many patients, right?

I've done what you did: I put them on the ice correctly, so I'm not trying to say that I do that every time, no, no, but I'm saying that in their case what I think is a victory is, uh, it's the Blood pressure is fixed, but that is almost a biomarker of the real problem that is being fixed and with it your risk of many things is decreasing, which is explained by hypercortisolemia and increased sympathetic tone and increased blood pressure . Yeah, I just find that. very fascinating and then what I was thinking this morning, you know, I'm going to talk to Peter about that, you know, one thing that fascinates me deeply is your practice, it seems like there are very few other practices, maybe globally, now we touch briefly the latter. 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 views as doctors and I'm fascinated for the people who come to see it. because normally in the NHS we recognized last time that we are quite bad at real prevention in medicine, the current way Medicine 2.0 is practiced compared to Medicine 3.0, as you describe in your book, but people in the UK United I would say Anna in the United States.

I'm sure I usually go to see your doctor with a problem, certain doctor, I have pain here, this hurts, you know they come with a problem they want you to solve, do your patients come to see you and your team with a problem? or they come to say Hey, listen, I want to make sure my fringe decades are the best they can be Peter, can you help me? Yeah, so if you compare, I think maybe a note that you would write when you see your patient, it would probably start with a chief complaint, yeah, sure, it would probably start with Mrs.

Smith came to see me today with a chief complaint of swelling. , reflux or pain here or there in our first meeting with a patient, um, the note. It actually starts with your goals and there we divide the goals into two groups, so they are marginal goals for the decade and goals for the next 12 months. Yes I love it. I think it's just a wonderful exploration of what could be possible and what true preventative healthcare could be. it seems and yeah, you say it's a luxury, but I guess you've created the opportunity for people to go and experience that and I guess you've learned a lot from doing that and creating that because we often don't.

I certainly don't have the luxury in the NHS to do many of the tests that you do having access to that data, what do you say? Because I was thinking, well, I don't think testing is the biggest limitation, I really don't. and we actually talked about this with our patients from the beginning, like in the first month or so. In fact, the first time we do a blood test check with a patient, we check her blood, I do a kind of soliloquy that every patient gets the first time. and the gist of it is something like this, look, there are several metrics that we're going to pay attention to over the duration of your time in this practice, so you could be in this practice for two years.

In this practice for 10 years, we don't know, but you will get used to a drill and a cadence in which we pay attention to things and most patients come into this practice with over-indexing on blood work because that's kind . Of you know that in your previous relationships with doctors that's what doctors pay the most attention to and we say, look, okay, like you know we're going to do blood tests and we're going to talk about that here today, that's We're here to talk, but you have to understand that your blood test is just one of the 30 to 40 pieces of information that we include in our risk assessment model, so your family history, which we talked about last week, and you already know.

The reason we send you home with a 10-page packet we need to complete is because we really want to know your family history, and you know we're going to do a movement assessment that's going to take two hours and finally a strength assessment that's going to take two hours. It will take a couple of hours. a VO2 max test and a zone two test and a dexa scan and a liquid biopsy like there's a lot of things and yeah we want to know your APO B and your blood glucose you know we're going to do an ogtt etcetera so the labs are just one of the 30 things that we look at and by the way, labs have big blind spots in that they are really good at helping us predict your risk of cardiovascular disease when combined with understanding your blood pressure and a few other things.

They are not really good at helping us understand your long-term cancer risk, or even your immediate cancer risk. I mean, there's just a stochastic process there, other than measuring metabolic health, this doesn't really tell us whether you have cancer or not. Well, we almost downplayed the importance of labs and I think the biggest impediment, from a time perspective, is actually the issue of movement, exercise, nutrition. We'll get back to the conversation in a few minutes. Right now, many of us are struggling to find time to eat all these amazing whole foods, which is why I'm a big fan of good quality whole food supplements like this one, which has been in my life for over three years and now contains more than 75.

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Do you know how to scale this? Why aren't there hundreds of other practices doing this? And I think that's the challenge: how do you scale those other pieces that require the custom nature? interaction with an expert in that area and we're doing some things, I mean, we're creating courses and videos along those lines, but um, it's, it's just going to take other doctors to say, I want to learn this. things well enough that I can then be the conduit for this information, but I will tell you that there are, I mean, in the UK, you are further ahead of the US and that you already consider that APO B, for For example, it is an appropriate metric for When measuring the risk of cardiovascular disease, you consider that APO B in the UK is superior to LDLC.

The United States is still behind on that. I think also what your model shows is true prevention and, in fact, without getting into policies and why the health system evaluates it. the way the big picture looks, if all patients had access to that, let's say take the UK, a government funded system, a tax funded system, if you could really do this for everyone despite the cost initial, it is very clear or I guess without running numbers, how can I say this? It would seem very clear that you will save a lot of money in the end, as if looking.

Why, by the way, do people always ask me if we can institute a system like this in the US and I? In fact, I say it's much easier to institute this in a single-payer system. Can you expand on what that term single payer means if someone doesn't? Yes, so a single payer system would be like the NHS, where you have the government as the sole payer, the government is the insurer, yes, and why is that? So a single-payer system, by definition, implies that the government is PL paying. We don't have that in the United States for everyone we have.

We have something called the CMS Medicaid Services center that serves people over 65 and something called Medicaid for people who know they qualify for very low income, but most people in the United States who have health insurance get it at through a private insurance company and that private insurance. The insurer will only insure them for a short period of time and it is actually even more complicated in the US because depending on the size of your employer, sometimes the employer is the bearer of the risk, but it is done through the services administrators of an insurance company.

All of this is to say that they really don't have the incentive to pay money today when you're 25 and 30 to avoid complications when you're 60 or 65 because they won't be the ones to insure you, so you'll have a different employer or a different insurance company, so if you think about the NHS or any single payer system, there really is an incentive to invest wisely when people are young and healthy to spend a little bit more because you're still single payer. in this case, the government assumes the risk of that life in the future, yes, so in many ways it is much more logical to consider medicine 3.0 in the context of a single-payer system than in a multi-payer system, that Now it makes a lot of sense.

I guess one of the obstacles to that is that the NHS is such a political hot potato that there doesn't really seem to be this 20 to 30 year Vision anymore, there's an election in two years, so what do I do? with the NHS to ensure I get re-appointed, which is going to be fundamentally problematic because decisions will always be biased towards the short term rather than the long term and of course these things require an upfront investment which is more painful in the long term. short term, you get the benefits in the long term just to finish your practice, since it's private, since it presumably has an element of cost and please correct me if I'm wrong, presumably it's only going to There are people with a certain amount of resources that can actually access them and then in a capitalist system, many of the people who end up with that resource, in my experience, are type A personalities who have worked hard and often don't always feel like there was something they were proven right , which drives them to incredible success in this system that can generate rewards.

I don't know if it's fair to say it or not, of course every patient is different, but if that's the case, are there certain patterns seen? on those individuals and then I guess we can learn from that if because a lot of people like Yorkshire listen to this show and may not have those resources, I'm always interested in this is a great model of practice, what can we learn from? Mind you, I mean, I think I think that as a generalization, that's probably a fair characterization, of course, there are a lot of exceptions, so you know you have to take that with a grain of salt, and the interesting thing is something that As I alluded to earlier , I think that sometimes people with higher performance and hyperactivity do it because they have something to prove and sometimes that need to have something to prove comes with other burdens that can undermine health both directly and indirectly, which is why I think that I realized that, statistically speaking, more wealth translates into more health, yes, but that is not true.

Beyond a certain point, in other words, it is true that knowing that an income of £50,000 a year will produce better health outcomes than having an income of ten thousand pounds. per year um and maybe having an income of one hundred thousand pounds per year will give you a better health outcome than having an income of fifty thousand pounds per year possibly I'm not sure, but what is absolutely false in my experience is having an income 50 million pounds per year versus one hundred thousand pounds per year. I don't see any difference in health outcomes at that level and in fact the multi million pound income person often comes with other problems, yeah, um and So you know one has to be careful what they wish for and I say this both for myself and for two others, and I think that one simply has to accept the fact that one only really has responsibility and accountability for one's own choices and one's own behaviors, and I truly believe that time is the most important parameter in this game, it's really not so much about resources as it is about financial resources, but it's about time, yeah, and that's an example of where, yeah, there can often be that person who's just barely making it. a situation where they also don't have time, you know they're looking for so many things together to make it work, but you know you mentioned exercise a moment ago, I mean, if a person could spend an hour a day exercising, I mean, they'll be more healthier than the richest person on the planet who doesn't do that, yeah, yeah, who has all the fancy doctors, who has all the fancy clinics, who does all the executive physicals, I mean, none of that will do it. it matters if they are nottaking care of themselves and I've seen people across the spectrum and the correlation is very vague, yeah, just to take them down.

Pizza you touched on and maybe we're not trying to get into this in detail, but since women have lower oriental levels after menopause, I know this is a pretty contentious area in terms of whether all women need hormones after menopause. menopause to protect the brain, protect the muscles, can you address such a nuanced topic? It's a quick overview. summary, in your opinion, do all women need it? Well, it's a very complicated topic and it's one that I've dedicated a couple of podcasts to and written a lot about. It's controversial, very controversial, I certainly found it. Unfortunately, it is controversial.

It's controversial for all the wrong reasons, meaning it's all based on bad information, 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 and, as you know, , very wrongly, allowed the media to misinterpret, misinterpret and propagate, and basically the conclusion of that study was that estrogen caused breast cancer when in reality the experiment showed the exact opposite, so the Health Initiative of Women actually showed that estrogen protected against breast cancer, but estrogen combined with synthetic progesterone. slightly increased the risk of breast cancer but not breast cancer mortality when I say slightly increased the risk I mean one case per thousand one there was one additional case per thousand of breast cancer zero additional associated breast cancer deaths with the estrogen-only group means that women who did not take estrogen with MPA, the synthetic progesterone, there was a reduction in breast cancer, which was true when the trial was stopped at five years and later when the data were evaluated 15 16 17 years later, so again it's just grotesque. misunderstanding of the literature, there are many reasons to consider estrogen, some of them have to do with symptoms, so vasomotor symptoms, and I would say that any woman who experiences vasomotor symptoms, such as hot flashes and night sweats, should not have to suffer. through them and therefore I think hormone replacement therapy makes a lot of sense in that context where I think it gets a little more nuanced: what about women who don't experience vasomotor symptoms and what about women They are going through the period of vasomotor symptoms, so let's say they went through menopause at age 50 and are now 60.

If they stop hormone replacement therapy, they would presumably stop it, no longer have symptoms, but they would also lose the protective benefits of the hormone replacement therapy. estrogen in your bones. The truth is that we don't. We have great data on that and we will never, no one will repeat the experiment to find the answer, but at least in our system I think it's much easier to detect breast cancer than it is to treat osteoporosis and, um, I think to each his own. a woman has to be something like that, I hate to say it, it's such an obvious cliché, but every woman needs to be treated individually and you basically have to look at what the symptoms of estrogen withdrawal are and are they trivial if a woman doesn't have problems with estrogen withdrawal and is very afraid of the consequences of estrogen for life, then that is probably the option for her.

Yes, I appreciate your brief overview of a very complex topic. I spoke to Professor Any Smokerjee a few months ago about menopause and its problems. That's how I hope to cover it. I think it is a very important issue and I think we will see. I imagine we would see more research on this, particularly in relation to cognitive health and what it means. deficiency may mean for the brain in the future, but again, that needs a proper and nuanced discussion in and of itself. Yeah, the Women's Health Initiative didn't really answer that question for us, there were a lot of flaws in that part of the study, so we looked instead.

In smaller experiments that have been done since then, certainly some of which suggest the protective benefit of estrogen for cognition, it may only occur in a subset of women, for example, those with exactly one APO E4 gene, for example. what is still to be determined and the The remaining time, let's see, we can cover cardio cardiac censor, what is Cartier zinc for people who have never heard that term before? Well, and I think there will be quite a few, although I think we often get seduced into thinking that our section of the internet is what everyone sees too, but we all consume highly curated feeds that give us what we already know, what we like.

I'm pretty sure my audience won't know the term, so why is it a key pillar of longevity protection when it comes to it? exercise for you, so this is complicated because it requires understanding a little bit about metabolism and how we make ATP from nutrients, so there are basically two pathways that we have at our disposal to make ATP. ATP is the energy currency necessary for every physiological function. So, to be clear, ATP is one form of chemical energy, but it is made from another. form of chemical energy in the form of food, so when we consume food and for the purpose of this discussion, let's just talk about two things, fat and glucose, since those are the most abundant sources of energy, fat and glucose contain energy in their chemical bonds, those chemical bonds.

It has to be converted into electrical energy which is then converted back into chemical energy. There are two ways to do it: there is a very, very efficient way to do it and a very, very inefficient way to do it. You might wonder why there is an inefficient way to do it. it's why you would do it that way it has to do with speed it's the speed at which you need the ATP if you need the ATP very very quickly if I told you I want you to get up and give me 25 burpees, do you know or do you?

Some of you already know, I want you to do a sprint at full speed for 30 seconds or for a minute, you are demanding ATP at such an accelerated rate that your body is going to lead you to a very inefficient way of converting glucose into an intermediate molecule called pyruvate. and then convert that to lactate and generate a little bit of this ATP. If I gave you all the time in the world, if I told you I wanted you to go for a slow run, your body, hopefully, if you're reasonably fit, will convert that glucose and maybe even the fat, ideally, the fat into smaller molecules. which go to the mitochondria and produce a lot of electrons which are then converted to ATP, so again I'm oversimplifying, but I guess what I'm trying to point out is that there is a slow and efficient way. doing it that doesn't have any byproducts except carbon dioxide and water and then there's an inefficient way to do it when you have a gun to your head and it doesn't produce much ATP and it produces a lot of lactate. and lactate binds to hydrogen in hydrogen making your muscles stiff.

Well, zone two is a term used to describe the highest level of effort you can sustain while keeping lactate below a certain threshold of two millimoles, why once lactate goes above two? millimoles starts to add up two millimoles for most people is the level at which you can sustainably eliminate it while creating more, so the fitter an individual is, the faster they can run or the more power they can generate in a bike while still maintaining their lactate at two millimoles or less and the difference is pretty amazing, so you mentioned kipchogee earlier. I don't know his numbers, but I'd bet kipchogee could run a 4 minute, 455 50 mile, certainly a five minute mile, while maintaining lactate. below two for many of us that will be beyond our maximum if you do it.

First of all, I couldn't run a five-minute mile anymore, but even if I could run a five-minute mile, you know I would have higher lactate. Also, yeah, sure, maybe even say five, yeah, yeah, so the same thing happens in cycling. They give you a look. You know, Tadi Pogachar, he could produce four watts per kilo on a bicycle and his lactate is also below. I could produce four watts per kilo. kilo for a few minutes before I fill up on lactate, so the point is that this is working on this specific zone and working particularly on a particular energy system that we need, yes, it is your maximum aerobic efficiency, so if the VO2 max is your maximum aerobic production VO2 max produces a lot of lactate but it is the maximum oxygen consumption you have is your maximum aerobic production this is different this is maximum aerobic efficiency the type of metaphor I use with patients is a pyramid VO2 max is the peak height of the pyramid, zone two is the base of the pyramid and the goal of cardio training is to have the largest area of ​​the pyramid, so you don't want a pyramid with a narrow, tall base, nor do you want a. with a short wide based peak, you want a big wide based peak, so you want a very high zone two threshold and a high VO2 max, yes thank you, it's a complex area.

I'll make one more point because the person listening to this might say, What the hell are you talking about with lactate? Here's the good news: a person who then says, "Okay, how do I put this into practice?", if Peter says, "Hey, we should really try to do three hours of zone two conditioning a week." The gold standard is achieved by measuring lactate, but the way we can do this in real life is simply by exerting under what we call rate of perceived exertion and this is the indication of when you are in zone two. you can talk but it's awkward and you don't want to but you can still talk in full sentences if you can if you can talk in full sentences easily you're in zone one and you're not getting that training effect so in other words it's not hard enough , so if you and I went for a walk right now, we wouldn't be in zone two because we, in zone one, could be in the flat terrain zone and have what we've been saying is correct if we went out. going for a run right now, well that would be a bad example because it would be easier for you than it would be for me, but let's assume for a moment that we did something where we were both in comparable shape and we couldn't talk to each other. or if we did, it would be a word here and there we would be in zone three, four or five, yes, and that would be beneficial, but not for this type of conditioning, yes, you have to thread the needle in that sweet spot and that is What you're basically doing is improving your mitochondrial efficiency.

Yes, I love it now and I would say that for much of my life I have greatly neglected this. I've always been drawn to intensity for a variety of reasons, not because I like it. feeling more because I've always felt quite pressed for time. I've had a lot of caring responsibilities for my parents throughout my adult life, but I was saying that the last few years have changed that completely and I'm spending a lot of time relating to the Past in zone two and what's real, I think for me, and there is a lot of content that you have published online about zone two and you have written about it beautifully in your book.

If people want to learn more, I'll cover it. Surely the program in short also the beautiful thing about zinc is that it is quite easy, don't you know? If you know. You get a little breathless when you say you can have a conversation you don't want to. of people stop exercising I think it's too hard and I find one of the best things about the zones. I really enjoy it because I think listening to a podcast listening to an album I haven't listened to in a long time or whatever and the recovery time is negligible so I actually feel like it improves my life and my cognition and I know it's doing something called Longevity, so I'm not sure how appreciated it is for people who are afraid of exercise and don't want to.

That uncomfortable feeling of certainty of a really high effort can become one of your best friends very quickly and is important even if you are the best in the world, so yeah, if you look at the Kipchogees of the world, they're still spending 80 percent of their training time in zone two, yeah, um, and you asked before, can you think of any way that What percentage of your time should you spend in each of these areas? I mean, that's really what it comes down to exactly, it's about 80 20. So it's about 80 percent of your cardiovascular time should be spent in zone two. 20 percent of your cardio time should be spent at a much higher intensity, but if you start reducing that, you'll run the risk of burning out during the workout and getting injured, yes, so if you do.

Say I'm going to do 50 of my time will be high intensity and 50 of my time will be low intensity or zone two. You're not going to achieve as good a result, but the most important thing is that I believe you are going to do it. To risk getting that injury and overtraining, we don't have time to go into this in detail, so let me summarize and correct me if you think I've misinterpreted any training that was given.Adjust to a VO2 max to really get that twenty percent. of time you're potentially working on that part of your fitness, unlike zone two of 80, it's usually done with longer intervals.

I know you do four minutes on four minutes rest, so four minutes really intense, four minutes rest, full recovery, beyond. kind of typical striking training again, that's a really quick summary because I want to be respectful of your time, yeah. The sweet spot is actually three to eight minutes, three ten minutes away from work with individual work to make up for three. So if you go in, if you exercise at such an intensity level that you can only do it for one minute on and one minute of rest, that's great, there's a VO2 max benefit to that, but understand that it's not. optimized for VO2 max, yeah, you're not going to do it long enough because you're doing it too intense, so that's fine, so if that person does well, you've got me convinced.

I need to get on my exercise train for my longevity. I can give you five hours a week. week, but that's all I have, how would you divide those four pillars into those five hours? It would depend on what your current deficits are now, so again, it's different if it's a person coming in who has done a lot of strength training and never done cardio or vice versa, but let's make it really hard and say it's a person who has never lifted a finger, so if that's the case, if you're a person who's never lifted a finger, you could do two hours of strength training, three hours of cardio and on your first cycle, those three hours cardio would be in zone two.

I wouldn't even add any VO2 max or stability. No, I would just say that for three hours a week I would do four 45-minute workouts in zone two and maybe in the last five minutes of each I would increase the intensity a little bit. Yes, but not even just to acclimate them a little bit to a higher workload and then the two hours of strength training that you might ask them to do. two 60 minute sessions a week where each session is full body strength training and they are really fundamental fundamental movements, there is nothing terribly fancy, some of them will probably be just bodyweight, and then I would re-evaluate all three months and at the beginning.

The question would be: Have you enjoyed this enough to want to add a little more time? They could say: I enjoyed it a lot but I don't have more time. Okay, cool, then we could say we're going to go. two and a half hours away from zone two and 30 minutes where there is now dedicated VO2 max training and we'll probably get further into strength training, so it's hard for me to say exactly, but that's the general thing I appreciate. it's very individual, it was more just to give some kind of guidance, a big apology for rushing through a lot of these really complex topics, like zone two and the maths of VAT, of course people can read more in the book or on his podcast.

In closing, pizza, better words if someone asks you, listen, I'm inspired by what you do. There is so much information out there. I do not know where to start. What do you say to them? Oh wait, that's hard. I guess I'd say just pick one thing. I mean, presumably the person asking this question has enough awareness to know where they are most efficient, either, hey, I'm really overnourished. I'm not very muscular. I sleep four hours a night. I would say pick the thing that you're confident you can claim a victory in and just do that for the next 12 weeks and really fix that pattern again, if it's your dream, really fix your dream, we haven't talked about that today. but you know again there's a lot to do there if it's nutrition, just understand it because it's so much about the confidence that comes from addressing that pattern and making incremental changes that stick rather than trying to make massive changes that are harder. . follow up so that's probably what I would recommend, thank you Pizza, thank you for the work you're doing.

I think you are inspiring a lot of people around the world to believe that they can actually do something right now that will help them in their marginal decade ahead on the show and enjoy your time in the UK. If you enjoyed that conversation, I think you'll really enjoy this one about the simple things you can do to improve sleep energy and reduce fatigue, the foundational practice I really believe in. every person should do every day is