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

In

your

experience, what are the common obstacles you encounter for people trying to make

change

s? I think it depends on the

change

s, but if so, leave that nuance aside for the moment. I think in some cases the impediment to change is just inertia. I mean, some

time

s 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, which for some people. I don't want to break a habit, so I'll give you an example.

I think you realize that that doesn't sound very clear. If you tell a person, look, you have to go to bed an hour earlier. It would really be great if you didn't fall asleep on the couch watching TV because that hour of sleep that you're sleeping on the couch then you have to wake up and go to bed like that, that's terrible quality. Sleeping well, the impediment. change is not that they don't understand, like you said, that sleep is important, but that they have an actual habit of sitting on the couch watching TV after you know they should relax and now you basically tell them, well, you're I'm going to have I have to come up with a new way to relax, so it's the introduction of "You Know You're G" to make a change, but it actually requires several changes and I think that underlies a lot of things.

I also think there are, you know, certain things that people have to do that aren't so pleasant at first? So for a person who has never exercised, I think it's actually quite intimidating and initially off-putting to exercise and you can tell them until you're blue in the face that once you get over the initial challenge of this, it's actually going to feel pretty good, really. You will appreciate the fact that it is not only beneficial to you in the long term, which it is, but even in the short term, but they have to be. Some

time

s you have to give a little faith to do that.

I think when it comes to changing behaviors, for example, like food, sometimes realizing that changing the default environment of food is very important requires a big

step

forward, so one thing is Say look, I want you to know that Stopping eating this way and starting to eat this way is 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. require less willpower and more automated behavior, yes, so 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 a single change, yes, it's usually multiple changes. they have to be set up to make the beh behavior of interest more automatic, yeah I'd say that very much echoes my experience.

I guess what I think about often with patients very similar to you, I think is that all behaviors are therefore a reason to serve. a role in our

live

s and I think we often try to change behavior without understanding what drove it, so is the sugar you crave at 99:00 p.m. on the couch really physical hunger or is it emotional hunger you know it's that you've had a shitty day it's that you've had a fight with your partner and that little bit of sugar is going to help you because if that's the case then you may need a different strategy it's that you feel lonely and instead of sugar maybe you want a phone call with your friends it's stress maybe you want a relaxing bath instead of that sugar, whatever it is, then I would say that's one of the key things that I have learned throughout my career.

Yes, you can change behavior without addressing that, but it tends to be short-lived. All year long you know you do it for two weeks when your motivation is high and then all of a sudden you've had that bad day at work and you need to pick up the kids and whatever, you know, that's too hard, like that. which is something that you spend time within your practice trying to understand because look, behaviors are great and I want to talk about more of these behaviors that we want people to do, but often it's not the behavior, it's the impediment to that behavior that what I find I spend a lot of time. of time with patience, I think we do too and 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 the right thing, that's, you know, there's not much of a mystery, it's going to be, it could be a mystery when they come in, there really could be some confusion about what the optimal strategy is around exercise or whatever, you know, one of the things that um, we try to remind people, I just think about it with the example that you gave, is um, try not to have two failures in a row, yeah, right, so the example that you gave there, for two weeks you'll be 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 go into a negative spiral when they beat themselves up about that bad day and feel ashamed that they missed their workout, something they set out to do. they set out to do what you know, they set out to do and that shame becomes the most dominant emotion as they get ready for the next workout and it becomes easier to miss the next workout and instead what I think you want to try is say look, you have that bad meal that you said you weren't going to do you missed that workout you do something that's a little out of your way um just give yourself a complete pass without judgment and just say yes, it's really hard like this was easy, you would have done it last year or the year before, or just do it right on the next one, just make sure the next meal is right, make sure the next workout is done, um and I, I even find this 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, but that's not always true and I still have to be very impartial and, when I slip, remind myself that Alright. and let's try to let it go tomorrow is that something new that you've had to learn has generally, absolutely, become more relevant as I get older, so, you know, I think when I was younger and even more selfish there were never Reasons to deviate, but now with a family with other responsibilities, there are many reasons to deviate and sometimes I consider those uses of my time to be better and as a result of that, I sometimes fight with myself thinking about what happened to you.

Yeah, look how much you're slacking off and inside, you know what you're talking about, but yeah, I think I'm a lot more compassionate with myself today than I used to be. Yeah, sure, I mean, he would scold me a lot. Myself in the past, if I said I was going to do something and I didn't do it, there was a lot of negative self-talk and you realize that it's never that helpful if shame or guilt is the underlying emotion that I just don't do it. I don't think it's sustainable in the long term, it will always surprise you at some point.

That's certainly what I felt, by the way, it's completely different. Going back to what the impediments to behavior change are, I find that there is another phenotype. I see that in my practice, which is um um another manifestation of trauma, which is basically the individual who is completely incapable of taking care of themselves or putting themselves ahead of others, yeah, so I see this phenotype more commonly in women um and I see this so often, you know, a mother who knows 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 her children before her own, but she does so to the detriment of her own health. Yeah, and she tells you that you know that's the case, so she 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 that you'll say "it looks like you." ". You have to carve out an hour a day to do these things and she says yes, I know I should do it, but then there are a series of excuses, but you realize that deep down what's happening is like there's some kind of way that's happening. of self-punishment. and I'm not saying that's true for all working moms who work their asses off, but I'm just saying that in the examples that I've seen in my practice I really attribute this to kind of maladaptive behavior around trauma and um and that's another one. example of what I, you know, I would describe that as a kind of emotional health failure that cascades into physical health failure, yeah, I would say that one of the things that I've learned and it influences what you just did. . said about this trauma that a lot of people have today, I would call them low-grade addictions, whether it's sugar or social media or online shopping or online browsing, whatever gets in the way of other behaviors because there's There are a lot of behaviors that people could do to optimize their long Jey, but I think this is a really important piece.

Do you know why people can't perform those behaviors? Why do many people perceive themselves as having no time? And I mean, I really like Gabel. My friend's definition of addiction, which is again, if I destroy it a little, please forgive me, but something has these three components, uh, any behavior or substance that you crave, that relieves pain or gives you pleasure and that you can't stop doing or give up despite negative consequences, so through that lens of looking at addiction, I would say that many of us, most of us, have some level of addiction and I'm interested, do you consider that to be a relevant area to address with your patients?

I consider these low-grade addictions to get in your way if you make potentially more helpful changes when it comes to your longevity, yes, but I would take an even further

step

back and say forget about the impact of these addictions on your ability to do exercise. or eat right or sleep right, I would say just talk about the impact of those addictions on your relationships um and and and I think that's the interesting thing about trauma that usually on some level underpins some of these behaviors and by the way, I think that term is very charged and people think that trauma has to be a Big T trauma, but actually a little trauma can be so impactful, sure, but not dealing with those things and not understanding that most of them. things produce really wonderful adaptations, but as a guarantee sometimes they have maladaptive behaviors, yes, and not dealing with those things can have the impact on the physical side that we talked about well, it will usually manifest itself in the form of not engaging in self-care. through those behaviors, those positive behaviors, but it can also be quite detrimental to your interpersonal relationships and I think if your interpersonal relationships are compromised, your quality of

life

is compromised, your happiness is compromised, your joy is compromised. and, you know, honestly, I think. that's equally problematic, so to your question I think the way to approach this 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 .

Most discomfort I see the behaviors that I am not performing correctly, i.e. I am not eating well enough, I am not exercising, I am not taking care of myself in the physical sense, while I think for others, how they are going to cope. That, they're going to go through destruction or damage in their relationships, whether it's with their spouse, their children, their friends, co-workers, that's when you really delve into this area and I know you. I've been on a personal journey with this as have I, it's increasingly about emotional health. I think it's not that physical health doesn't matter, of course it does, and you know being physically healthier, of course, helps us with our emotional health. well, but I feel like the emotional health part does drive better self-care it does help your relationships, but you know, there's a lot of research that shows I have to be very careful expressing this because I'm absolutely I don't blame people, but now There are strong associations between people holding on to negative emotions, holding on to anger and resentment, being unable to forgive, and risk of water immune disease, and again, I'm not blaming people. associations in the literature if I look at my own practice, my practice outside the NHS was largely filled with people with autoimmune diseases.

Many women saw these types of personality traits frequently. I don't know if you're familiar with Fred Luskin. Working at Stanford on forgiveness and the ability to forgive on blood pressure is really very interesting and I think I followed you for years, Peter, and that's why you strike me as someone with whom you have openly shared things that you measure in your own life. right for many years, I often think about that phrase that you know not everything we measure matters and not everything that matters can be measured exactly, so yes, we can measure key metrics and we talk about some of them, uh, the first time he came to my program but there were some other types of immeasurable problems that I find increasingly impactful for health.

I'm thinking specifically of a patient. I think she was 48 and had slightly elevated blood pressure. I do not remember exactly. numbers, but I'm going to assume that she was in the region of 135 to 140 out of 90 something like that and duringSix months we are trying to make changes with Al Lia, she transformed her diet, she started exercising, you know, she started prioritizing her sleep, yeah, I couldn't get her to move. I couldn't help her move and I did and we mentioned it correctly and we followed up 24 hours a day and I thought. What am I missing here now?

Of course some people will balk, maybe she needs phal, but in talking to her I felt like she was holding on to a lot of Banger and it turns out that as I got to know her more, she had actually separated from her ex-husband who had cheated on and couldn't let go, but ABS just couldn't let 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 we did, but essentially over the next few months she basically learned the ability to forgive. She managed to let go of the anger she felt and her blood pressure normalized.

That's a final thing. I'm aware of that, but I'm sharing that with you because these things really teach me that there is all kinds of information in a human being that manifests itself in their physical health and I didn't learn those things in medical school, I just learned them. I just look and then I go to the literature and see that that's research that supports it. We now have the same quality of evidence for that as we might have for a particular form of exercise for blood pressure. No, 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 feel like it's as important as the harder side and I guess I love your thoughts and perspectives on areas like that oh I I would completely agree with that uh in all aspects correct meaning that I think that matters absolutely I think it's very difficult to quantify, yeah not impossible, absolutely, for me, the most important question is, do you know how to teach it well?

So how did you get that patient? I think most people wouldn't blame her if she basically said, "I'm going to do it." carry this, you know, an ax to grind for the rest of my life, most people would say I got it, yeah, get it, so how did you work with her to convince her that it was worth trying in the first place? forgive her? ex and then secondly how did he actually do that? Yes, first of all, I believe in informed consent, so I explained the situation to him. I explained the risks of not treating that blood pressure in terms of its long term.

He and I explained to him what. the options were that he had also established a very good relationship with her. I got to know her. This is one of the beauties that nowadays it's hard to be fair, but certainly a few years ago there was still that continuity in primary care where one in the NHS here, where you would meet someone, you would meet their family, you could really see who they were. in their lives in a way that you don't always achieve with hospital medicine, so I had built a very good relationship with her, she trusted me, so I don't go there with every patient.

I just got a sense of her, so you know when the time was right in a consultation, when I felt like she was open to, I said, listen, you've done an amazing job with all the changes that you made to your lifestyle. I would have expected to see some change here, not always, but generally my feeling is that I learned a couple of things about myself that I think maybe at play here, would it be okay if I talked to someone with you if you were interested and I mentioned it and the first time I mentioned it, you know, brick wall, she wasn't willing to go there, but I would like to see patients regularly, even if it was just 10 minutes.

She would do it often. retrieve 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 said, "Look, we can put you on your medication or we can try this because I think this might help you." blood pressure but frankly I think it will also help you in many other aspects of your life, for example if you hold on to this, I understand and I explained to her that forgiveness would not be for her ex-husband, it would be for her and me .

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

I think I often refer her to a psychotherapist. I don't think she wanted to. She would build trust with me, but the point is that yes, it was difficult, but I believe that not only helped her with her blood pressure, but it will also reap dividends in multiple aspects of her life, emotionally and physically, for years to come. I am convinced of that and I agree with you. I think there's a subtle point there: I think it's a better health outcome than just addressing it pharmacologically, so if you had given her an Ace inhibitor or an ARB, you would have cured her. blood pressure, but you probably wouldn't have fixed the underlying sympathetic tone, the hypercortisolemia that was still going to have negative health consequences and I've done that with a lot of patients, right?

I've done what you did, I put them on the ace, so I'm not trying to say that I do that every time I don't, but what I'm saying in your case is that what I think is a win is that blood pressure It was fixed, but that is almost a biomarker of the real problem is being solved and with it your risk of many things is decreasing, which is due to hypercortisolemia and that increase in sympathetic tone and increase in blood pressure. Yeah, I find that fascinating and then when I was thinking this morning. You know what I'm going to talk to Peter about.

You know, one thing that fascinates me deeply is your practice. There seem to be very few other practices, perhaps globally. Now we touched on this briefly last time about our different experiences. in the US in a private system and I 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 by what people come to see you because normally in HS we recognized Last time we were pretty bad at actual prevention in medicine the way Medicine 2.0 is currently practiced compared to Medicine 3.0, as you describe in your book, but people in the UK, I would say , and in the United States, I'm sure, they 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 are your patients coming to see you and your team with a problem or are they coming? to say Hey, listen, I want to make sure my fringe decade is the best it can be, Peter, can you help me?

Yeah, if you compare, I think maybe a note that you would write when you see your patient would probably start with a chief complaint, yeah right, it would probably start with Mrs. Smith came to see me today with a chief complaint of bloating, reflux, or pain. here or there, in our first meeting with a patient, the note actually starts with their goals and there they split the goals into two brackets, so they are marginal goals for the decade and goals for the next 12 months, yeah, I love that , I think it's a wonderful exploration of what could be possible, what true preventative healthcare could look like, and yes, you say it is. a luxury, but I suppose you've created the opportunity for people to go and experience that and I suppose you've learned a lot from doing it and creating it because we often don't have the luxury, certainly in the NHS, to do a lot of the testing that we do. you do having access to that data, what do you say? because I was thinking, okay, I don't think the test is the biggest limitation, I really don't know, and we actually talked about this with our patients early on, 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 kind of give a soliloquy that every patient gets the first time and the gist of it is something like, look, there are several metrics that we're going to pay attention to during your time in this practice, so you could be in this practice for two years, you could Being in this practice for 10 years, we don't know, but you'll get used to an exercise 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 It's something you already know from his 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 a blood test and we're going to talk about that here today, that's what we're here to talk about, but you need to understand that your blood test is just I don't know one of the 30 to 40 pieces of information that we include in our risk assessment model, so your family history that we talked about last week and you know the reason we sent it. to home. a 10 page packet to fill out is because we really want to know your family history and you know you're going to do it, we'll do a movement assessment which will take two hours and eventually a strength assessment which will take a couple of hours and a V2 Max test and a Zone 2 test and a dexa scan and a liquid biopsy like there's a lot of things and yeah we want to know your apob and your BG you know we'll do an ogtt Etc so labs are just one of the 30 things that we look at and by the way, labs have big blind spots, as labs are really good at helping us predict your risk of cardiovascular disease when combined with understanding your blood pressure and some other things, um, they're not really good for helping us understand your long-term cancer risk, including your immediate cancer risk.

I mean, there's just a stochastic process to that, other than measuring metabolic health, this doesn't really tell us whether you have cancer or not, so we almost downplay the importance of the labs and I think the biggest impediment, from a health perspective time, it's actually movement, exercise, nutrition, sleep, that's the challenge. I'd have it in 10 minutes, right, that's why 10 minutes can't just make that happen and people say to me, you know Peter, why aren't you scaling this? Why aren't there hundreds of other practices doing this? I think that's the challenge, is how to scale those other pieces that require the personalized nature of interaction with an expert in that area and we're doing some things, I mean, we're creating courses and videos. that line, but um, it's, it's, it's just going to take other doctors to say, I want to learn this stuff well enough so that I can then be the conduit of this information, um, but I'll tell you there, I mean, in the UK. , you are. further ahead of the US and already considers apob, for example, to be a suitable metric for measuring risk.

He was asked if he considers apob in the UK to be superior to ldlc. The US is still behind on that. I think also what your model is showing is true prevention and in fact, without getting into policies and why the healthcare system is set up this way, you are just taking a short break to thank Vivo barefoot shoes. Now I have been a big fan of bare feet I live for over 10 years now, long before they started supporting my podcast, they are the only shoes I wear and they have really had a huge impact on my own life and the lives of many of my patients, you see it when people start wearing minimalist shoes like alive. we can see improvements in things like back pain, hip pain, knee pain, foot pain, even things like plantar fasciitis can often improve and scientific research shows us that just using Vios for about 4 months improves foot strength by over 60%, which is One absolutely amazing thing that people don't realize about these shoes is how flexible they are, allowing your feet to do what they naturally want to do instead that the shoe dictates the movement of your foot.

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It is easier to institute this in a single-payer system. Can you expand on what that term single payer means if someone doesn't? Yeah, so a single payer system would be like the NHS, where you have the government as the sole payer, the government is the insurer, yeah, and why is that like that? A single-payer system by definition implies that the government is paying. We don't have that in the United States for everyone we have. We have something called the Medicaid Services Center (CMS) that serves people over 65 and something called Medicaid for people who know they qualify. for very low incomes, but most people in the United States who have health insurance have it through a private insurance company and that private insurance company will only insure them for a short period of time and, in fact, it is 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 administrative services 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, um there really is an incentive to invest wisely when people are young and healthy to spend a little bit more because you're still the Single Payer, in this case the government takes over the risk of that life in the future, yes, so in many ways it is much more logical. considering medicine 3.0 in the context of a single-payer system than in a multi-payer system, that 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 203 Year Vision, rather there's an election in two years, so what do I have to do with the NHS? to make sure I get re-elected? Yes, which is going to be fundamentally problematic because the decisions are always going to be biased towards the short term AND instead of the long term and of course these things require an initial investment which is more painful in the short term, you get the benefits in the long run just to end your practice, given that it's private, given that um presumably there's an element of cost and please correct me if I'm wrong, presumably it's only going to be people with a certain amount of resources who really They will be able to access that and then, in a capitalist system, many of the people who will end up with that resource are Type A personalities who have worked hard and often don't always feel that there is something to prove that is right, which the drives you to achieve incredible success in the system that can reap rewards.

I don't know if that's fair. say or not of course every patient is different but then if that's the case there are certain patterns that are seen in those individuals and then I guess we can learn from that if a lot of people like your show and listen to this show . I may not have those resources, so I'm always interested, this is a great practice model, what can we learn from that? Yeah, I mean, I think I think as a generalization, that's probably a fair characterization, um, of course, there are a lot of exceptions. So, you know, one has to take that with a grain of salt, and the interesting thing is something you alluded to earlier.

I think sometimes the highest performing, highest performing people do it because they have something to prove and sometimes. That need to have something to prove comes with other burdens that can undermine your health, both directly and indirectly, and so I realize 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 having an income of £50,000 a year will produce a better health outcome than having an income of £10,000 a year and perhaps having an income of £100,000 a year. will give you a better health outcome than having an income of £50,000 a year Possibly I'm not sure, but what in my experience is not entirely true is having an income of £50 million a year versus £100,000 a year.

I don't see any difference in health outcomes at that level and in fact the person with the you know, multi-multi uh million pounds of income uh often comes with other problems yeah um and so you know one has to be careful with what one desires and I say that both for myself and for others um and I think that one just has to accept the fact that you only have responsibility for your own choices and your own behaviors and I really believe that time is the most important parameter in this game, it's not so much about resources like financial resources but it's about time and that's an example of where yeah, that person who's just barely making it can often be in a situation where they don't have time either, you know they're looking for so many things together to make it work, but you know what you brought up a moment ago, I mean, if a person could spend an hour a day exercising, I mean they'll be healthier than the richest person on the planet who doesn't do that, yeah, yeah , I appreciate who has all the fancy doctors he has. all the fancy clinics that do all the executive physics, I mean, none of that is going to matter if you don't take care of yourselves and I've seen people all over the spectrum and the correlation is very vague, yeah, just to finish, so Peter you touched and perhaps we don't have time to go into this in detail, but given that women have lower levels of ease after manopause and I know this is a fairly contentious area in terms of whether all women need hormones after menopause to protect the brain. cognitive protection muscles, can you give such a nuanced topic a quick and general summary, in your opinion all women need it?

Well, it is a very complicated topic and it is one to which I have dedicated a couple of podcasts and many In writing to you, it is controversial, very controversial, I certainly found it to be controversial, unfortunately, it is controversial for the wrong reasons, which means that everything It's based on bad information, so all of this controversy around hormone replacement therapy stems from a trial called The Women's Health. An initiative that was published 21 years ago that, 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 fact the experiment showed exactly the opposite.

So the Women's Health Initiative actually showed that estrogen protects against breast cancer, but estrogen combined with synthetic progesterone slightly increases breast cancer risk, but not breast cancer mortality. When I say slightly increase the risk, I mean one case in every thousand and one. one additional case per thousand of breast cancer zero additional breast cancer deaths associated with that in the estrogen-only group, meaning that women who did not take estrogen with MPA, the synthetic progesterone, there was a reduction in cancer of breast, which was true when the trial was stopped. at 5 years and subsequently when the data were evaluated 15 16 17 years later, again just a grotesque misunderstanding of the literature.

There are many reasons to consider estrogen. Some of them have to do with symptoms, so vascular symptoms. And I would say that any woman who experiences Vaso symptoms, such as hot flashes and night sweats, should not have to suffer from them and therefore I think hormone replacement therapy makes a lot of sense in that context where I think it becomes a bit more nuanced: what about women who were not experiencing vasomotor symptoms and what about women who 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 stopped hormone replacement therapy, they would presumably stop it, no

longer

have symptoms, but they would also lose the protective benefits of estrogen on their bones. The truth is that we don't have great data on that and we never will. 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 I think every 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 so are you. basically you have to look at what the symptoms of estrogen withdrawal are and if they are trivial, if a woman experiences no problems with estrogen withdrawal and is very afraid of the consequences of estrogen for life, then that is probably the option for her .

I was at a practice. an NHS practice in a very low socioeconomic area, a lot of low income, a lot of poverty and there was someone who, you know, was coming in, he had all sorts of problems that I was trying to help him with and you know, he was fighting for time and He was like look I don't have time to do this I'm busy I'm doing this but when we really figured it all out and looked at how he spent his time when he wasn't at work, he was doing things like going to three or four stores a week to different stores to save money. .

He was driving, I think 20 minutes out of town to get cheaper gas, and in the context of it all, I won't tell the whole story, but essentially we figured it out. I was saving very little money but spending about 4 hours a week for it so we came up with a 4 week challenge, say "good" for these four weeks instead of saving that and appreciate that money is tight and he agreed. Wasn't it me cajoling him into doing something he didn't want to do? I told him that with that time savings you could go for a walk, you could spend time with your kids, you could do all kinds of other things and I'm not kidding.

Peter, that chain literally over the course of 6 to 12 months starts to transform your health because you suddenly realized that, wait a minute, everything in life has a cost and in fact, the cost of going to the gas pump on the roads, which is a bit. It's more expensive, but it actually gives me a lot more time to take care of myself and he, you know, a year later, the guy had lost weight, he has a better relationship with his kids and his wife simply because he needed someone outside of himself to take care of him. will help to understand. that actually everything in life has a cost, often we just don't weigh it, yeah, look, that's a beautiful example, um, and it's, uh, I think it's something that, as you point out, is not always easy for you. see it for yourself when you're the one in this is this is where it really helps uh he was lucky to have a doctor that with the limited system of having 10 minutes with a patient because most, I think most doctors wouldn't necessarily have the ability that you had, that is, hey, I'm going to think beyond the immediate problem that I have in front of me, which is that your blood pressure is too high and you're overweight, and I'm going to start thinking about this from the point of view of your life, so it's very lucky to have had that and you know, unfortunately, I think that's probably not common, right?

I think a lot of us go through life making these trade-offs that are generally pretty irrational, so we bring up APO. B well, in terms of the things that you think a lot of us should look at and then potentially aggressively treat if it's elevated or if we have a strong family history or whatever it might be and just to be clear, state this This is shows very well in the book for people who want to dig deeper, that's something we've mentioned and that not everyone can have access to both in the US, I think, and here, but before we move on from apob, if someone doesn't you can get that and all they have at their disposal is a standard lipid panel of total cholesterol, LDL triglycerides, and HDL.

How would you advise them to analyze it to properly evaluate their risk? As I said, non-HDL cholesterol, which can be calculated by taking total cholesterol. and subtracting HDL cholesterol that gives you a number, um, I mean, you know it's the poor man's version of apob and it's a better predictor of risk than LDL cholesterol, so you know, I guess in the UK your units are Millo , not milligrams per deciliter, so I'm not familiar with the unit system either, but there are tables available that will demonstrate the percentiles, yes, so what we suggest is that a young person should really be below the 20th percentile or below of the 20th percentile and the younger you are, the less aggressive you should be because this is kind of the area under the curve problem, so it's really a lifetime exposure, just like blood pressure is right, You know, if you have high blood pressure, even if it's slightly elevated for a while.

Over a very long period of time, it will cause proportionately similar damage to a person who has higher blood pressure,but over a shorter period of time and similarly with apob, you know if you start reducing this when a person is 30 years old, you won't. I don't have to make a huge change outside of cases where people have familial hypercolemia or things like that, versus when someone shows up in their 50s and already has evidence of aerosis on a CT scan, then you're going to have to do a lot. much more aggressive, so you know, I mean, I would just say directionally to someone who has some evidence of atherosclerosis.

Basically, you're now treating it as a very high-risk secondary prevention case, even if you haven't had a heart attack, which is typically what we would use to enter the world of secondary prevention if a person has the Cal app on a CTA or a CT. A coronary CT scan that is effectively secondary prevention, we would want non-HDL cholesterol or Elio cholesterol to be below the fifth percentile, that is a good point. Pizza, which I think a lot of people haven't really understood that if you already have signs you don't have to wait. It's, it's that analogy of smoking again, you know, wait until you're on the precipice, you know, wait until you've had a heart attack, okay, now we know what we're dealing with, now we can implement secondary prevention, it's like no, you know.

We don't need to wait for that moment, it's so basic and obvious when you put it like that, it's quite remarkable that we seem to have arrived at a system where we don't treat early and I understand that. I understand the pressures within the medical system. I understand why we end up working like this. Why, of course, you raised the case. We need to improve medicine. Now we rethink medicine. But that's a really, really good point. Have numbers you can. search I know, don't worry about UK units, people can easily convert Is it there? Knows? Do you have numbers with these ratios like the ratio of triglycerides to HDL?

Would you like to see it below a certain amount, for example? Well, it's important to understand that. Although the ratio of triglycerides to HDL cholesterol suggests insulin resistance, it is not related to the risk of atherosclerosis. In fact, I think we write about this in our newsletter, we have a newsletter that comes out every Sunday and it's usually nice. We delved into these topics and did a newsletter on this particular topic about the value of knowing your triglyceride level. We certainly pay attention to it and become alarmed whenever triglycerides exceed 100 milligrams per deciliter, which tends to be alarming and certainly.

If the ratio of triglycerides, cholesterol, triglycerides and HDL cholesterol is above about two, we also tend to think of that as a red flag, although most people would say three, four or even five would be the threshold, we think. that any value greater than two is a red flag. triglyceride ratio cholesterol HL, but this is the interesting thing once you normalize for apob, there is no residual predictive value left for htl cholesterol, triglycerides, total cholesterol, those things become completely irrelevant once you know apob and basically cholesterol non-hdl, in other words, once. you have the non-HDL cholesterol level set that captures all of your lipid risk.

Now the only exception to that is the LP, but we can talk about that separately. So based on what you just said, in a hypothetical scenario where people were given the option to say they can have a test to measure their risk of atherosclerosis, a blood test, yes, and they had to choose, and I appreciate that we are not in that scenario, but as a thought experiment, I would say that a test should be a Yes, there is no ambiguity about this, it is that the literature is overwhelming. In fact, I don't know of a single study that suggests there is a lipid biomarker superior to apop.

There are some studies that would suggest that non-HDL cholesterol is almost as good, but overall, when you look at all the literature in general, it is unequivocal that apop is the superior biomarker, but I want to be clear and I don't want us to get hung up on this. because I know your audience might I don't have access to apob, so I don't want perfect to be the enemy of good, yeah, if you don't have access to apob, okay, the jugular point here is knowing your non-HDL cholesterol, knowing your cholesterol LDL and control it. aggressively and the reason non-HDL cholesterol is better than LDL cholesterol is that it includes VLDL cholesterol by proxy and therefore includes the negative impact of excess triglycerides, which is why you asked a question earlier about triglycerides and you are absolutely right, elevated triglycerides are a risk for cardiovascular disease and they are a risk that is not captured by LDL cholesterol but they are captured in vldl cholesterol and that is why apob captures them both because apob is the concentration of all the atherogenic particles and so as the level of triglycerides increases so has the number of lipid-transporting lipoproteins because now they have to make way not only for the cholesterol that they are trying to transport back to the liver but also for this high triglyceride load and that is again why apob is a superior metric, but If you don't know apob and for some reason you don't know non-HDL cholesterol, then yes, you need to know triglycerides and LDL cholesterol to capture the full risk before continuing with this topic.

Thanks for summarizing that, Peter, for people who don't have access, but let's say that by any means you discovered that you have higher levels of apob or non-HDL cholesterol than you would ideally want. You mentioned that there are some pharmaceutical interventions that can be used, what kind of lifestyle interventions that people can do to reduce that, the most important ones are those that reduce triglycerides because of everything I just said a few years ago. moment, that is, the higher the triglycerides, the more lipoproteins you will need to transport them and, specifically, that is the vldl very low density lipoprotein that eventually becomes a low density lipoprotein, so the question is what should do to lower triglycerides, so that the people for whom dietary interventions are most potent in lowering lipids are the people who have the highest level of triglycerides as As a general rule, when I see people who have very high LDL cholesterol and very low to normal triglycerides, we don't waste time with a dietary intervention, with one exception which I'll come back to in a moment, but in most cases.

In part we recognize a genetic defect generally at the level of the LDL receptor that is responsible for this problem and must be addressed pharmacologically, but let's go back to where we still see a lot of room for intervention, which is a person with elevated apob. or LDL cholesterol, not cholesterol and also very high triglycerides, so the easiest solution here is usually carbohydrate restriction, so carbohydrate restriction is usually the quickest route to lowering triglycerides, but it comes with a problem Carbohydrate restriction generally means increasing fat consumption and in susceptible people. People who increase fat intake, especially saturated fat intake, will through a totally different mechanism increase cholesterol production and that's what I was referring to before, which is the other dietary thing you should always keep in mind. when you're looking down a very high barrel.

Ldo cholesterol or apob is what this person's intake of dietary fat is and, in particular, dietary saturated fat. Yes, if a person is sensitive to that, cholesterol synthesis and dietary fat will increase. High levels of saturated fat will affect the removal of LDL from circulation through the liver. Yes. That's a great point and I also agree in my experience: there is nothing faster and more effective at lowering triglycerides than some type of carbohydrate restriction, but as you say, you shouldn't just look at triglycerides in isolation because it doesn't. You know what else could be happening as a result of that, it's another example of the question you asked before, you do something with the lifestyle, you cut the carbohydrates and solve the triglyceride problem, but if you do it by incorporating coconut oil or what whether it's your saturated fat, you're going to drive yourself into a sky-high abyss, you're probably worse off than you were when you started, there's a yin and a yang to everything, yeah, and there's obviously this big debate online about how much that means. important in an aggressive diet, let's say a low-carb diet, for example, you know, I'm sure you've been involved in this.

I've seen it all, like the conversations about how much this really matters if hscp, the marker of inflammation, is low. you know how much we should worry about other things potentially increasing and you know I don't think this question is as nuanced as those advocates would say, it's no more nuanced than you saying, how much should a smoker worry about smoking? if they are otherwise healthy and fit, maybe less than a non-smoker, uh, maybe less than a smoker who is not healthy and fit, but does something for that smoker's physical fitness or good health, it decreases the causality of smoking with respect to cancer.

No, yes, and similarly, if you tell me that a person is on a low-carb diet and they're insulin sensitive and their inflammation is low, but their apob or LDL cholesterol is still through the roof, that doesn't change the fact that we are still at risk as a result of that. Again, this is why causality is so important. The person who has familial hypercholesterolemia may be metabolically healthy. In fact, many of them are right. You know, you diagnose this in a child who is between 15 and 20 years old. they are thin they are thin they are healthy their hemoglobin A1c is 5% their biomarkers are flawless but they have premature atherosclerosis due to lifetime exposure to LDL cholesterol of 200 milligrams per day so I think people who suggest that just because you're following a low carb diet and your other biomarkers are fine, but you know and can ignore your LDL cholesterol.

I think those people are playing a very dangerous game of Russian roulette and I hope that the people who pay attention to them Blood pressure, of course, is also a very important metric that we need to pay attention to and of course for many years it has There have been home blood pressure cuffs available whether your doctor is doing it or not and of course there are some pretty big limitations to rushing in, getting your car parts quickly and actually, hey, yeah, take it. to my blood pressure doctor, of course, there are some real issues there, but talk a little bit about blood pressure because what I love about addressing blood.

The pressure is that, first of all, in terms of us being blind to what's going on inside our bodies and then somehow at 50 or 60 we have problems. Blood pressure is something we could overcome fairly early if we started paying attention. As? Do you see the blood pressure? How do you frame it with your patients? um, yeah, and then maybe we can go deeper into the treatment, depending on where we go with this. Yes, I'm really glad you mentioned this. There are a handful of regrets that I regret. Writing the book regrets is the wrong word, nothing could have been done about it, but I guess I would say that there are a handful of topics that I wanted to delve much deeper into, but as you know, the book is almost 500 pages long.

There is simply no room to go any further, which is why this book is 60,000 words shorter than the previous version of this book; in other words, an entire book was cut from this book and one of the topics I really wish I had put more energy into is This exact topic and I would say it is just as important as the apob discussion, but for a slightly different reason. Sorry to interrupt. If you are enjoying this video and want to learn more, you can download my free special guide containing six simple breathing practices that will help you calm your mind, reduce stress and improve your energy.

To get this guide, all you have to do is click the link in the description box below and the reason is that here you have a physiological parameter that not only shortens your length. when it comes to cardiovascular diseases, but it also does so with respect to Alzheimer's disease and dementia. By the way, we didn't talk about that with apob, but apob is probably also reducing apob is, I would say, one of the three most powerful interventions to make. prevent dementia and Alzheimer's, maybe let's bracket that and go back to that thing that doesn't get enough attention, you know?

Along with exercise, lowering lipids is unambiguously the best way to prevent Alzheimer's and Alzheimer's. dementia, but so is lowering blood pressure and the other thing that doesn't get as much attention is the impact of high blood pressure on kidney function and how important this becomes in an aging population and, while you know, this rarely causes a person of 40, 50 or even 60 years to enter The problem begins tobecome very problematic when people are in their 70s and 80s and when you have very compromised kidney function, you are much less likely to live to be 90 years old and you also become much more susceptible to toxins. that you know that your kidney would normally leak when your kidney is functioning at a quarter of its capacity, so blood pressure, as you said, is partially complicated by the fact that we as a medical community do not do a great job measuring it in our patients. so you very precisely mentioned the exact problem, right, what is the patient, you know, park the car he has to run up the stairs, sit in the reception area, you know, they rush you back, they take his blood pressure arterial with an automatic cuff and that number no.

Tell us a lot. I mean, we know from the Sprint trial that there is a very clear protocol on how to measure blood pressure and that you should sit comfortably with your legs uncrossed and not talk for five minutes. Either the automatic cuff or the manual cuff should be used. placed exactly the right way, so that the mark on the cuff aligns with the brachial artery and so that the cuff is at the level of the right atrium, that is, where the superior and inferior Hava vein empty into the heart. You know, I think it's interesting and I do this all the time just to show people who take a blood pressure reading with their arm significantly above or below the heart and they'll be surprised at the difference in pressure.

It is very sensitive to this finding, for this reason we generally recommend that our patients get one very high quality monitor and we usually direct them to two or three that we like and allow them to purchase them on Amazon or at their local pharmacy. We give them a record electronically and ask them to check their blood pressure twice a day in the morning. in the afternoon or evening according to this protocol and we don't even do evaluations on this until we have at least two weeks of data, but now we can believe that we can trust that data and now we know if those numbers average above 120 out of 80, we should take measurements because again this is where the data is best found.

The blood pressure studies carried out make it very clear that treating with lifestyle or factology at more than 120 over 80 has significant benefits and results even over 130 over 85, where historically we used to consider the upper limit of normal, yes, it is so Well. point, measuring it correctly, of course, is very important, otherwise people can go out and buy something at the local pharmacy, try to take charge of their health and then start to stress because, in reality, my blood pressure is really very tall, this is a couple. Of the things I have to discuss about Peter, one of them is trackers in general because certainly, as someone who has watched you online for a number of years, you've been pretty open about what you track and have shared many times about the There is a type of things that you track and of course not everyone is a professional tracker and my opinion is that it often depends on the personality type in terms of, you know, I've had patients in the past, let's say 10 years ago, for example, um .

It seems to remember that maybe you know and I say 50% of patients this is just a rough guess, but basically about half of my patients when they were saying I should take my blood pressure on Monday and they were saying it would be helpful. I said, sure. Why don't you grab one and, you know, let's see what happens or measure it right now? What I found is that maybe half of the patients would measure maybe three or four times a week and use it as a way to keep them on track for the lifestyle change, it would help motivate them, while the other half I found I would start checking it six times a day, if one of them was slightly elevated it would make them anxious, probably make their blood rise.

Pressure for the rest of the day they would be calling, so I thought, okay, is this good or bad going back to what you said earlier? Peter Well, it depends in a way, it depends on who you are, so I like who you are. By doing it as a practice where you have this protocol in place, you're not really looking at those individual numbers, it's like you do this for two weeks and then let's take a look and see what the overall pattern is. I think it's useful. since many people will take their blood pressure at doctors in this suboptimal way or pick one up at their local pharmacy.

Where do you see trackers here? I know I heard you say a moment ago in a conversation that you were reviewing. I have discovered some of these risk trackers. I hope we get to CGMs because I think CGMs are one of the most powerful tools I've seen for changing behavior in my two decades of practice. I don't think I've ever seen anything so powerful. in real time, do it, but just to finish a little bit on blood pressure, where are you doing that with your kind of research on this kind of non-invasive monitoring at home? So, first of all, I just want to reiterate what I've said and I completely agree.

I think people tend to specialize a little bit in minor and minor in major and tracking is a tool. People tend to get distracted by the tool and miss the substance, the substance is the information of the tool and what you do with it and, for some people, tracking is a very valuable information generation tool and for some people is also a very valuable behavioral tool, which we will talk about with CGM um, but when I see the debates between the tracking community and the anti-tracking community they seem religious, political, partisan and uninformed, yes, and that's why I try to distance myself a little from that.

I have a point of view about the benefit of these things, but it's me, I find myself less interested in debating it because I don't find the debates to be full of merit, they tend to be, again, they just tend to, you know, degrade into a kind of useless debates, especially online, right, that's never been in my experience. You know, on Twitter or on Instagram, especially on Twitter, it's very unlikely that you're going to get to some kind of meaningful place at the end where everyone has learned a little bit and everyone understands it. I know, as a fellow podcaster, I feel this. debates or these kinds of things, long-form podcasting I think is the best medium to have those conversations because the nuances and the context emerge within them, whereas online is like you say it deteriorates very, very quickly, so that, like you, I simply stay away from them. and the distance and I say what I have to say on this podcast basically, yeah, yeah, and I've had really interesting discussions with people, um, about people who might disagree with me on various things and, yeah, these discussions when they you have adequately. over the phone or whatever, they tend to be much more productive, when it comes to blood pressure, I would have to assume that even the harshest critic of monitoring as a general concept would have to at least maintain some interest in continuous blood pressure. monitoring, yes, because this is something where there are many limitations of spot checking, so even if you overcome the limitations that we just described, which are numerous, you still have the limitation that even if you do it perfectly, you are only looking at two points in time yeah, you don't know what your blood pressure is at night, you don't know what your blood pressure is when you're working, when you're on the phone and you're stressed or when you're making dinner. or all of these other things and what we would really like to know potentially is what is your average blood pressure over the course of a day and today the only way to really do that is with a 24 hour ambulatory blood pressure monitor, which It's called abpm. and I've used one of these before, so it's a real cuff that you wear on your arm that's connected to a normal blood pressure machine, except it's smaller and set to cycle every 15 minutes, so you wear this for a couple of days you take it off when you shower but otherwise you wear it 24/7 and it just works like a normal blood pressure cuff every 20 2 hours but the problem is which is so cumbersome that it's not really of much use. and for someone like me who doesn't really mind being tracked, I found it so cumbersome that I quickly got rid of it, so there are now devices available, one I've played with quite a bit, that measures blood pressure. optically from the back of the wrist and are calibrated for automatic bracelet measurement.

It's too early to say what I think of these devices, but I'm very curious and very hopeful and optimistic that these things will work. because I really believe that it is information that I would like to know from all my patients. I would really like to know what your average blood pressure is and I think it would probably be even more important to know what your average blood glucose is. Yeah, I mean, I'm pretty sure we'll solve this problem, right with technology as it is, whether it's now or 6 months, 12 months, two years from now? It's inconceivable to me that we won't have it at some point. a great non-invasive blood pressure tracker that actually gives us that information, I guess, in a way that CGM does well, in a way that gives us information in a way that you can barely tell you're wearing one.

Just going back to blood pressure, your goal of 120 over 80, as you say, is lower now is more aggressive than what we were certainly doing five or 10 years ago in medicine. Is there a specific essay that made you realize this? I think there are quite a few, but you know where, yeah, I think I think in the most recent Sprint test we saw that what was then described as aggressive management versus standard management there was a difference and the answer was yes, there really was a difference and Would you go even lower, so again? Lower, you are saying with apop that you strongly believe it is better for your atherosclerosis risk.

Can we say the same for blood pressure? Know? What happens if it goes up to 115 or 110 whenever? Of course, you won't get Disney Nur or well, that's the big problem, if that's true. I mean, you know blood pressure is one of those things where the symptoms matter a lot on the low end, they don't matter on the high end, in other words, we. We're not going to wait until people have symptoms to say their blood pressure is too high, but we certainly will back off if the symptoms are low and that's why you know it's me, you know I'm a lot slower to turn around. . to pharmacological interventions on blood pressure than to lipids because you don't pay such a high price on the lipid side, right, you don't need apob.

This is a big misconception that you have a lot of essential cholesterol in your body floating around. without apob, children have an apob concentration of 10 to 20 milligrams per deciliter, it is nothing and yet children have no problem with the deep and rapid period of growth they go through, including their central nervous system, yes , right, so think of all these people who say, "Oh my God, you can't lower your cholesterol because your brain will starve." I mean, there are C orally meaningless. The most aggressive voracious appetite the CNS has for growth is during a period of life when you have the lowest cholesterol level.

There is no disadvantage to lowering cholesterol except for the side effects of the medications that are used to do it and we have discussed them and they are important and you have to understand them with blood pressure, it is quite different, it is not so much the side. The effect of the medication is the side effect which, by the way, has side effects, but the much more dangerous side effects are the dangerous side effects of hypotension and orthostatic hypotension in particular, so I would rather exercise and lose weight. and improvements in sleep, as you know, and that includes correcting sleep apnea if it's present as the first three second third line agents to correct hypotension because the body is much better at self-regulation in that setting than if it had to resort to something pharmacological and we would do it.

We really only want to use pharmacological agents when we've reached the limit of those other three. Yes, that's a great point and any practicing doctor will be well aware of the problems with blood pressure medications, especially with our elderly populations. a small dose and then all of a sudden you know they get dizzy when they're standing there's all sorts of things to deal with so I think that's a really nice way to look at it you know it's your threshold risk or you're depending on the downsides or of potential. downside of that treatment so it makes a lot of sense blood pressure when you look of course we have an in person medication so over Zoom you can't tell how tall I am but I'm 6' 6 and a half. 2m high, sure, and the reason that's relevant is when we look at these generic numbers, like the blood pressure you want to treatat 120 over 80 mhm and this is, of course, where Nuance comes into the practice of medicine.

What if someone like me is super tall? you know, and you could potentially argue that some people on the extremes may know that I may need a little bit higher blood pressure because I have a lot more vasculature to pump my blood around my body. I'm not saying it necessarily does, I'm just putting it out there as a theory about how much these things are taken into consideration or when the data is as clear as it is with blood pressure, everything is fine, let's keep treating aggressively whenever we can. I have no negative symptoms, yes, no, it's a great question and it's a question I've been asked before when it comes to especially tall patients.

I guess the short answer is: I don't know, yeah, I don't know. I don't think I know the answer. One way I would think about it is considering that, as tall as you are and you know you're seven and eight inches taller than the average person, the real question is what is the height difference between your aortic valve and you know the vasculature of your brain because that's really the part of blood pressure that's working, that's the most important profusion part of the equation, right, that's the part that's most concerning is do we have enough central profusion in you because the rest of Your body is working a little less outside of gravity, in other words, that's the part where the heart has to pump against gravity.

Obviously your heart is receiving profusion regardless of your systolic blood pressure which is examined during diast and everything below your neck is aided by gravity to some extent so that might be one way to think about it, Which is, even though you are eight inches taller than the average person, how much taller are you in an area where your heart works? gravity another way to think about it and I haven't done this analysis is to look at the blood pressure of, say, a giraffe versus another large animal that isn't as long or doesn't have as much distance between the ventricle and the brain and I'm curious to know, I remember that at one point I read that analysis and simply forgot the answer, yes, really very interesting.

I love the way you think about this dilemma, um, the giraffe-watching type. It's really interesting, especially because you know, some colleagues or friends of mine know that they call me a giraffe, so you know, I like what you're doing there without that knowledge, but also this is a broader point for me that I've been on. thinking in particular. I know you have a movement coach. I think my name is Beth, based on what I remember from the book. I and I see a lot of similarities between you and me, Peter, in terms of approach to medicine, certain personality.

Traits we might have had are currently trying to be eliminated or reduced, but I have my equivalent of I guess what I perceive as your relationship with Beth. I have a lady called Helen Hall in the UK who is one of the most knowledgeable people. about the human body and movement that I have ever come across and you know there are all kinds of things that we do together to optimize the efficiency of my movements and you know my muscle sequencing and efficiency and all kinds of things, but let's take running as example. A lot of people who talk about running will talk about the cadence should be around 180, you know, feet per minute, something like that should be your cadence and you know I would read this and absorb it and try to implement it.

I would get metronomes. I would try to stay at 180 and say this is like I'm fighting here. This doesn't feel like I think it should feel through my work with Hel and I've been working there for about three years and now she says wrong. I just don't think it's right for you. You have super long legs. It's just a simple example of how generic advice can start to become problematic if you don't put in some context. So currently my cadence, which is beautiful for me, is about 162 and she saw me run, she measured me, which is quite different from 180, but I'm also quite different from average.

Broker, that's the kind of context behind my question, no, I, actually, it's funny to mention that example. I was the same in swimming. I mean, there's really a clear idea of ​​what your swimming cadence should be in terms of arm rotation and, um, my cadence is significantly slower than anyone else I've swum with. I have never swum next to people. I've never swum next to a person who has a lower cadence so for some reason my swimming style was such that it was better for me to rotate my arms less and just pull harder and glide, try to glide more um and every time I tried to catch that cadence um it usually backfired so there was no rhyme or reason to it and it frustrated me to no end until I finally accepted it and said this is my Cadence.

There's another point I want to make going back to your particular example, which is where I think we can be more judicious in using other biomarkers to help us understand. The trade-offs, for us, one of the most important biomarkers is cystatin C, which we tend to rely exclusively on and not creatinine when it comes to understanding kidney function. We tend to ignore creatinine completely, because it is greatly influenced by muscle mass. state of exercise things like that it always seems, I mean, I would say without being partisan, 80% of the time I think kidney function is underestimated or overestimated to the point of being useless, so we're looking at cattin C, which I think the The literature makes it very clear that it is a very superior biomarker for kidney function and of course we test it once a year so we will test it every time we look at a person's labs and then once a year we will also look at urine. protein and things of that nature, and that might be another thing you can try if you say look, I'm going to go a little out of the box when measuring blood pressure and accept a slightly higher level is to say okay. is my cyat and C very, you know, it's low enough that I can say that my estimated GFR based on Cat and C is still very high and if you see any compromise there, the first place we look, of course, is the blood .

Pressure, so the starting point is exercise, is the number one factor for our longevity. You were recently asked. I think it was in the Q&A that you guys posted on your show that a guy who plays tennis twice a week and basketball twice a week, is that OK? 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 decathlon is and then I'll come back and your question is interesting so the centennial decathlon is a model that we tend to anchor the marginal decade, so again the marginal decade, the last decade of your life, 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 that we just described as your centennial for catlon, so you might have a lot of goals in that marginal decade, you might know that hopefully you should have some cognitive goals, uh, hopefully you'll have some emotional goals, Vis A V goals, relationships um, but when it comes to 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 that There are some of these that many people would have on their 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 care about, what would you say?

I'm sure most people wouldn't mind if you knew that I want to be able to pull a 50 PB bow. I love archery, so you know, and I currently shoot like a 75 pound bow, but I still want to be able to draw a bow. 50 pound compound bow um, I still want to be able to drive a race car at about 5% of the speed I can drive it today, you know, Paul Newman up until a few months before his death was still driving this, you know, almost at their best moments, so you know, those are really strange esoteric goals for me, um, but I also have much more generic goals that I think make sense, since I would still like to be able to walk up five flights of stairs without interruptions. to be able to go down five flights of stairs, those are different, they require very different types of strength and um um Integrity of the musculature um I want to be able to get up off the floor uh I want to be able to sit on the floor for 20 minutes and I want to be able to get up on my own. media 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. outside of a crib I want to be able to lift a child off the ground, so there are a lot of these other goals that I have now. How can you do that right again? I think if you're listening to this, you're scratching your head. Thinking a little, they actually sound very easy, how can those goals be? 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 in 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 M, but no one is faster in doing all 10 things. that they do span both track and field events and they are generally considered to be 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 for 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 accomplish those things, so now let's get 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 beefier 85-year-old I said I believe? whether 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 are not building a very broad aerobic base nor a very high cardiorespiratory level. .

The peaks are both very intermittent. Sports start, stop, start, stop. They are interval training and that is fantastic. Interval training is a very efficient way if you didn't have other time to get bits of both the aerobic base and the aerobic peak, but it's no substitute for having a very broad base and a very high peak, plus they're not doing much for you. your strength directly, they are not doing much for your stability, in fact, they are challenging your stability, so if a person says I love doing those things, I say great, keep doing it if a person says I want to be able to do those things when be 0 years old.

I say great, I think it's doable, but you'll need to train to make sure you have the strength, stability, and stamina to do those things well. Yes, it's a wonderful framework for looking at aging and I like the idea that you have your patients write down specifically what are the 10 things I want to be able to do in my marginal decades. I heard you say once that A couple of people will say I want to helicopter ski, is that 40 year old person who says I really want to helicopter ski when I'm 95 or is helicopter skiing a way of saying I want to be independent and be able to enjoy the mountains and nature?

Whether they do or not, the point is that you know that by articulating it it means that they can develop a specific program with you and your team to help them accomplish that, yes, completely and the other thing is that these things can be malleable, I mean, yes, you asked me this question 10 years ago. I don't know if there might not have been 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 they wouldn't have even been on the list and there would have been other activities on the list that weren't Are they such a high priority for me today?

So, for example, now in my fringe decade, I'd be happy to swim, you know, half of it. a mile I think one of my things is being able to swim half a mile in 20 minutes. How did you get that? Well, you know, swimming used to be very important to me. So, you'll know again if you had asked me this a decade ago. I probably would have wanted to swim 10 miles and I would have overindexed on swimming and been able to swim really long distances, whereas now swimming is a lot less important to me, so it's mostly about being I can still enjoy the water andYou know, if now it's swimming half a mile, that would be enough, you know, can I float in the water?

You know, one of the things I have now is can I get out of the pool on my own again without a ladder, could I get up on a pool deck and get out of the pool so I'm less focused on time in the water? , but you're right, um, if you go after skiing and when? We have patients who 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 you're going to have to be a lot stronger in five years than you are now to adequately reach glide speed to where you will be at that moment and, by the way, if you miss or fall short, you will still be able to do it. a lot of cool stuff, yes, but let's go for it, yes, no, I love the approach that you bring a specificity to something that would otherwise be vague.

I just want to be okay while I'm older, which means okay, like okay, why, yeah, that. That's what we really try to get people to understand is that no one, no athlete, and you have to think of yourself as an athlete. No athlete has ever achieved something great without specificity. I mean, pick any athlete who is doing something today that is exceptional. Do you think they're out there, whether he likes it or not, thinking Jokovic is like yeah, it would be great to win Wimbledon? I'll just play tennis a little bit each week. I'll just play a little tennis each week.

I mean, there's no chance, yeah, I mean, there's no chance, over and over again, like we live in a world where sports science has made it very clear what it takes to achieve these physical things, so really 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, there'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 we can do. I've never before seen, say, Kip Chogi running a marathon in under two hours, something that was considered physiologically impossible, maybe 10 or 15 years ago, but for some people it's not possible for the human body to implode on its own or it will. whatever, so it's shown that that's We may be seeing world records left, right and center coming down.

We're seeing, you know, Premier League footballers playing into their 40s. You know, things we didn't think were possible yet, at the same time, so it looks like the elite are getting the benefit of all the latest sports science and what? Do you know that new limits are being surpassed in what humans can do? However, it seems 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 children in 28 different countries who basically observed that I think compared to 30 years ago, the average speed that a child took and this is between the ages of seven and 17, the average speed it takes to do one mile. rose slowerson 90 SL is 90 seconds slower, so there is some irony, there isn't, it's a great point.

Two things you said P, that I think are really important. Number one, the point you made if you think If you're going to be fine, you probably haven't spent a lot of time with 70, 80, 90 year old people or if you're going to be fine doing nothing and unfortunately in my own life I've Realized it this year. I won't go into all the details, but my mom, who lives 5 minutes from me, on the night of Christmas Day, had a fall, she was admitted to the hospital and was in the hospital for 3 weeks, there wasn't enough to get her out.

She would come into bed and do my own rehab. I know how quickly one can lose fitness and unfortunately since mom came home 3 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. What I needed to address was um, if you haven't seen it, you might not take it as seriously as you need to and then the other point related to that and I kept this page open in your book, is in the chapter on Training 101, but the graph you pulled from Jason Clifford and Brigham Young University.

I spent a lot of time looking at that graph. I think everyone should see it. This is figure 11, yes, figure 11, yes, this is the decrease in V2 Max, it is absolutely remarkable. The main point I understand from you is that the decline in your physique is inevitable. It will happen. You've said before that we understand at what pace it's likely to happen and I think it's great that it goes this way 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 able to do some specific things at 40.

Now a lot of people who listen to this show, Pizza Do Park, They host community events every day. Saturday where you run or walk 5K MH, so I don't know if you're up for doing a little experiment here, but this graph basically has... well, maybe you'd want to explain the graph because you're probably better off doing it. which I, sure, yeah, so the graph shows you could probably do it from memory, but it shows three three lines, so these lines are placed against the X and Y axes, so the x axis is your age and it's obvious . increasing progressively to the right and the AIS Y shows the V2 Max.

Now I don't remember how much we argued about V2 Max at the beginning, so they didn't let me explain this first, so V2 Max means maximum oxygen ventilation, so what? It's ventilation, uh, ventilation rate or oxygen minute ventilation rate, it means how much oxygen you're using at any time, so ventilation rate is defined in liters per minute and, um, you and I sitting here right now having this discussion we are probably at 3.4 liters per minute, maybe 0.5 liters per minute because we are a little animated in the way we speak properly, so we have an oxygen consumption of 500 CC per minute if we were to stand stand up and walk through this room. maybe it would increase to 1 liter per minute if we went out and ran around, you know, that would increase to 2.5 liters per minute and eventually if we kept forcing ourselves to exercise at an increasing pace and pushing ourselves it would reach a maximum, yes, and that can be tested in a laboratory, so it is done on a bicycle or a stationary treadmill because you have to put a mask on your face and the mask is what can measure the amount of oxygen. you're consuming and this is one of the most important tests that elite endurance athletes do, so if you talk about elite endurance athletes, it's usually going to be cyclists, cross-country skiers, runners, whether it's Kip chogi or Teddy pogacha .

You know, I mean these people have astronomical V2 Max, yeah, so the higher it is, the fitter you are, this is your maximum aerobic capacity, uh, uh, it's normalized by weight, so ultimately , the numbers you are used to seeing are reported as if you knew a number. Let's say 50 uh and it becomes milliliters, so 50 milliliters per minute per kilogram, okay, the higher that number is, the fitter you will be and you know, we have tables that tell us that and I think I put one of those here that tells you. it says by sex and by age where you sort by percentile now this graph shows something different, it shows people at the top, I think 5%, yes, in the middle of the group, so the median or the 50th percentile and the 5% lower and shows over time. how those three lines decline, they all decline, they all decline, and in fact, the rate of decline is actually steeper for the fitter people because they're starting at the highest point, but even though it's steeper, they still do it.

They have, they always stay higher, they stay higher. That's right, you always want to be on the top line. What this graph also does, which I find interesting, and the reason we included it in the book, is that it shows various levels of activity and what they correspond to in terms of a given V2 Max. which can be observed when several people pass each other, so at this point I have lost my ability to memorize it, so I will simply resort to the graph, for example, climbing stairs quickly requires a V2 Max of about 32 ml per kilogram per minute, it doesn't matter your age, right, if you want to climb the stairs quickly, that's true, whether you're 30 or 90, you need to have about 32 milliliters of oxygen per kilogram of body weight per minute, okay, now here's the interesting thing. people in the 50th percentile of the population at the age of 25 have a V2 Max of about 44, so they can do it quite easily by the time they reach 50, they have dropped to that level, so a person in my age 50 half of the population's fitness level is right at the point where they are going to lose the ability to quickly climb a flight of stairs and from there they are only going to go down, interestingly someone in the bottom 5% even at the age of 25 he is below that level, well now let's look at someone in the top 5%, someone in the top 5% who, by the way, at the age of 25 is about 62 in terms of his V2 in terms of their V2 Max, they don't reach that level of being right at their threshold until they're 75, so one of the things I find interesting about this graph is that it stops at 75, so one of the reasons we show this chart to our patients is to say oh and why we hold it to a higher standard than this chart.

We demand a standard of being from our patients. It's an aspiration, but this is where we want everyone to be. We want everyone to be in the top 5% for someone 10 to 20 years younger and the reason is we want you to be able to thrive in your last decade of life and you've said pizza before. There is no reason why most people can't be in the top 25%. It's absolutely not there, it's just there. I mean, you'd have to have mitochondrial disease to not be able to reach 25% of your age, so this is really empowering. I think for people, no matter how old you are, the earlier you are, the better you want to have a margin of safety. so let me summarize to make sure I've got this right, make sure everyone follows that essentially your V2 Max is a super important metric, it's going to get worse as AG in a relatively predictable way, so if you want to do it something like climbing stairs quickly when you're 80, we know what V2 mats you need when you're 80 and therefore we can say what V2 mats you need today and it's such a logical and beautifully simple way to look at it and it makes it very, very tangible.

The reason I mentioned parkour and pizza is because one of the things he talks about in this graph is jogging at 6 mph on flat ground, so 6 mph is about 10 minutes per mile. The pace, yes, it's right, 5K, so it's a park run for anyone who runs in the park. I appreciate that some people walk, but that's about half an hour of running in the park. I think a lot of people, I know a lot of people my age or 10 years older than AR are in great shape, but they can do 5K in 30 minutes, so what's really interesting to me is I mean it's brutal, this graph is absolutely brutal, right, if you are around 37 years old, it will take you a year.

I don't have exact lines down, so if you're 37 and can run in the park in half an hour, like when you're 75, you can barely go up a very gentle hill at 3 miles an hour, yes, if at 37 your limit It's just being able to run that 30-minute park run. At 75 you're going to have a hard time moving, so in other words, at 37 you need to be working hard on that park run, you need to run it in 21 or 22 minutes if you want to make sure that when you're 85 you don't have any physical or mental impairments. That is, the way I describe it to patients is that I am not, I am not so delusional as to think that at 80 I will be doing what I do today, but rather what I want.

I know what I can do when I'm 80 is take a train across Europe and take my own luggage with me and I pay attention to what that means now I pay attention to how quickly I sometimes need to move through a train station with my luggage and even now I know sometimes you have to rush, so now is not the limit of my ability today, but if I trust that that will be the limit of my ability when I'm 80, I know what level of fitness I should be when I'm 50. years, yes, and it's much higher, decline is inevitable, so you have to give yourself a buffer, and again, to be clear, I understand that not everyone is a runner, so it's not like you have that. do a 30-minute 5K or be, you know, some equivalent version, whether yeah, I'm not, I'm not a runner either, but it can be other things, so I do most of my cardio training on a bike or a treadmill or what if on a treadmill I do it on a steep incline or on a stair climber, yeah, um, and I've just decided and I just keep going back and forth, sometimes I want to run again because I used to be a runner, but it's like If you knew what I'm not going to do.

I'm going to save my joints. I'll let it go, but there are many things that stillI need to be able to stand up. I love being outdoors. So I swing a lot and that's a great way for me to add the element of conditioning and for people who have never heard that term rck, would you mind explaining it? Yes, it is walking with a very heavy backpack, so I walk. Our whole neighborhood, since I live in Austin, it's all hills, so it's great to go up and down really steep hills with a weighted backpack and depending on, you know, sometimes I go with 60 pounds, which is what I normally do, and there are other days where I really want to push myself, I'll do 100 pounds and um, and you know I'm walking, but it's still the most exhausting thing you can imagine when you're carrying that much weight to walk, you know, go up a hill, that's 15%. . degree with more than half your body weight on your back, so you don't have to be a runner.

I think that's the point of trying this system and the other thing that's important to understand is that it does everything at the end of the day. Get down to what you can do standing, so being able to walk on an uneven surface, being able to go up a hill, those will become the speed-limiting steps as you get older. I want to go back to something you said earlier and I'm sorry to hear this news about your mom, but it's actually a sad example of a very important point that I now write in the book about the fact that mortality from a fall if you are over 65 and you break your hip or femur reaches 30% in a year and most people included me when I first learned about this literature because I did a full AMA on this topic and initially when analysts because I have a team of analysts who help me with everything initially when they were releasing this literature.

I was like, guys, this is nonsense, use your logic here, there's no chance the mortality could be that high and they kept showing me document after document and this is often the case, the analyst keeps showing me data. and I'm not willing to believe it and I'm like, guys, come on, you're being stupid here like, yeah, I love that you're logical, guys, it's like wait a minute, yeah, yeah, and it's like, oh, you're actually right, You know? So, you know, I would say a very conservative group is 15 to 30% of people once they reach the age of 65, if they fall and break a femur or a hip, they won't be alive in a year. , but here is a statistic. which I didn't include in the book and I wish I did because it's just as important that 70 to 85% of them don't die in a year, 50% of them will have a complete reduction in level of function on a unit measure.

So, for example, if they used to walk freely, they will now need a cane for the rest of their life. If they needed a cane before, they will need a walker. If they needed a walker before, they will be in a wheelchair. In other words. There's a huge cost to this and there's actually another graph that I think is very sobering that shows the mortality associated with accidental death by decade and, appropriately, so in the US we're very obsessed with accidental death due to opioids. um because this last year was the first year that that number of deaths exceeded 100,000 in the US, it's a staggering number.

I think that's 106,000 people who died in the US last year due to opioid poisoning, but on a population-adjusted basis, that's nothing compared to what Falls affect people over 75; that's the graph I have there, which shows deaths normalized by population and all other forms of accidental deaths, of which the other two big ones are overdoses and motor vehicle deaths, which are completely dwarfed by deaths associated with falls . Yes, the point here is that most people between 40 and 50, I mean, it wouldn't even occur to us that you could fall let alone that a fall could be the end of your life at that time or, more commonly, at next year, yes, it's incredibly humbling to hear that, of course, I've seen it firsthand with my mom, a demonstration that this idea fits well with what we've been talking about, although now we may be talking about strength per se or of a mix of strength and stability.

I guess the tapering principle of the V2 mats is the same type of thing, but we're going to taper off and it's its strength and it's its stability and it's, you know, the point where we're going to taper off, we need a buffer space. so that if we fall and break our hip when we are 65 we don't want to be in that. 30% bucket, we don't want to be in the other 50% bucket of those who are, they are not dead, right, we want to be in the other bucket where we are, I don't know what percentage is where you return.

Your baseline prior to all of that is what we want and to do that we need to build a buffer right so that you have these four pillars of exercise or movement when it comes to being that generalist that is able to do the things that you want to do in your marginal decades. so you have strength, you have Zone 2 cardio, you have V2 Max and you have stability and I really want to make sure that we make this as practical as possible for people, but I'm wondering if it's worth giving a broad overview at this point. four pillars and I don't know if we can say this or not, but what percentage of time maybe without feelings about it we should defend each of them, yes, like this, then, you got it right, those are the four pillars that I will say. that we have the most data and the most clarity around two of them, strength and V2 Max um, so the strength and V2 Max data is undeniable, which means we have so much epidemiology that is so uniform in its direction, so strong in its signal, um that And I analyze this in detail in the book because I want the reader to understand the difference between good epidemiology according to Austin Bradford Hill's criteria and weak epidemiology, for example.

For example, what we see in nutrition, where it is very difficult for epidemiology to analyze. noise signal uh, but in exercise that's not the case and I review all the criteria why, so when epidemiology says that having a very high V2 Max leads to a

longer

life, I mean, it's crystal clear, yeah, and by the way, we have I didn't mention it, so it's worth mentioning, everything we've talked about so far about Visa V2 Max has been in the context of quality of life, which for most people matters more than duration of life, but it is worth noting that a high VO2 max is associated with lower all-cause mortality to a greater extent than any other health metric, including not smoking, not having high blood pressure, not having coronary artery disease, not having end-stage adrenal disease, none of them compare to the damage they cause more than being out of shape. so the hazard ratio association for being in the top 2% of V2 Max compared to the bottom 25% is a hazard ratio of more than five.

It's just an amazing yes, it's almost as amazing when you consider having high strength. at low force it's almost as powerful, it has a risk rating of over three and for people who don't know the risk rating, Peter explained it in depth in our first conversation, yeah, yeah, okay, so let's talk about these things, why is strength so important? Why is stability so important? And stability, 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 or section of this book which is three chapters, but stability itself is one of them, stability basically. it's the ability to transmit force from the body to the outside world and vice versa stabbing and uh without getting injured would be the easiest way to explain that so every time you take a step you're transmitting a force to the ground that's what that's what it propels you forward but a force is transmitted in the equal and opposite direction towards you, so what keeps your knee, hip and back from getting hurt is stability, what allows you to do that efficiently is stability , so typically 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 are doing an exercise standing on one leg, let's say you are. doing a single leg RDL or something, you'll notice that foot moving like crazy to try to preserve balance, a deadly Romanian RDL for anyone not familiar with that, yes, but look, stand in front of a mirror and stand on one leg and watch your foot Watch what you need to do and we think of that as balance but balance is like the reading state of stability yeah most people have probably heard of different types of muscle fibers fast twitch.

Muscle fibers and slow twitch muscle fibers, well, fast twitch muscle fibers, type two muscle fibers, are the muscle fibers that give us power, slow twitch muscle fibers, and I'm oversimplifying a little bit, but they are the ones that are of that type. This gives us more resistance so you can have strength in both fibers, but the explosive power comes in the type two muscle fiber, well that's the hallmark of aging is the atrophy of that type two muscle fiber, so wait when you hear about from fast twitch, some of us will go to Yes, if I want to be a 100 meter sprinter, that's what I need.

What is the relevance of that when you are 880 years old? Because when you're 80 years old, if you lose your balance. slightly and let's say you're stepping off a sidewalk and you lose your balance, you need to be able to react with enormous force and those are those fast twitch, the term fast twitch and slow twitch is unfortunately a little bit misleading while it's completely true that fast twitch fibers they contract faster, what that really means, and the real reason we use the terminology is that they fatigue quickly 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 it has lower power, very slow fibers to fatigue and unfortunately, as we age, we lose the first and much of the injuries that we see in people as they age is the direct result of the atrophy of that powerful MUSC muscle fiber that fatigue quickly. train it, you can maintain it now, you never will M no 80 year old man is going to walk with the volume of fast twitch muscle fibers that a fit 30 year old man has, that's not going to happen, but a well trained man A person An 80 year old can still have the fast twitch muscle fibers of a 60 year old and that's what we want to have, we want to know that we still have some power in those muscle fibers and that's why, for example, lifting heavy weights It is essential for everyone. at any age, whether male or female, so 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. It's a complete misconception, which is why 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 a huge impact on these type two muscle fibers of the that we were talking about fast twitch and sprinters. I just want to clarify that when you're lifting weights, do you need to do it with speed to really help that fast twitch fiber or does just lifting a heavy weight slowly also count as a stimulus for that particular thing, does it still?

You don't have to lift it quickly so it all comes down to weight so you have to lift a weight heavy enough that the type two muscle fiber is recruited and if the weight is not heavy enough the muscle just will recruit the weight slowly. Fiber contraction to get the job done, yes, if we 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, it's just observations of humans in blue zones or wherever this. What I find 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 do it.

It's also pretty obvious that most of those people live in environments where a lot of the things you write about were being automatically covered, let's just say I don't know a farmer in Sardinia who still hurts goats who are about 80 years old, well , it's like climbing hills, walking a lot, V2 Max, probably lifting things. I I I just think it's always good to step back and be okay, these guys weren't measuring every metric, they weren't looking at these decline charts. I feel and wonder what you guys feel about this is that because of the way many of us live now, we need these frameworks to help us achieve what these guys are doing naturally, yeah, would you see it any other way? ?

No, I see it exactly that way. Do you remember the original Spider-Man story? You have Peter Parker when you know when hethey shoot his uncle Ben, yeah, and um you know right before his uncle says something to him which is you know Peter, with great power comes great responsibility and I always have that in the back of my mind when I think about modernity. Do I like the fact that it's 2023 now? Or is there some reason you would want to go back to 1923 or 1823? If you gave me a time machine, the answer is zero chance, there is no chance I would want to. go back to 1923 or 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 and 300 years ago, 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 what way of You're considering considering our own, but even if you consider only Homo sapiens is correct, just think about the last few hundred thousand years of evolution, which really gave us our superpower to Leap Frog ahead of all these other species It was our MH 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 at energy storage, which served us incredibly well until relatively recently. energy became so abundant, of course, in the form of food that superpower became a detriment, yes, and now most people in the developed world are overnourished and we are on the wrong side of the energy curve, yes Does that mean we should all aspire? Going back to being hunter gatherers 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 a responsibility.

The same goes for movement that our ancestors did not deliberately exercise if they saw that there were things like gyms and treadmills, they could not understand what we were doing, but this is all a construct that we had to create, yes, to compensate for the fact that the modern world has eliminated the need for all movement. of our lives so we have to go further so maybe if you know if you're listening to this and you're a person who doesn't like to exercise that's fine but understand that there's a big responsibility that comes with living in the modern world for yourself, yes, and although you know that your ancestors five generations ago did not exercise, they did not need it because of what they were doing in the book, you argued that exercise may well be the most powerful.

Longevity intervention that exists number one. Do you still maintain that since you pressed print and the manuscript went to the editors? And if so, why do you put it right at the top? The answer to the first question is very simple, yes. I certainly do, um and the answer to the second question is also pretty simple, which is to say, it's not really a matter of opinion, it's simply a matter of data, the data makes that very clear. I kind of alluded to this a moment ago, but um. perhaps for the sake of the audience we can explain what a risk index is, so a risk index is a number that communicates the relative risk of one condition in relation to another, for example the risk index associated with The all-cause mortality for a smoker versus a non-smoker is about 1.4 and statistically what that means is that a smoker is about 40% more likely to die in a given year than a non-smoker. , all things being equal, that's what 1.4 means and you know if we had to do it. look at something, some intervention, I'm making this up, but you know, drinking a certain type of tea, if it had a risk index of 0.91, we would say that that intervention is associated with a 9% relative risk reduction if the risk index risk is one. it means there's no difference okay so that's the math on risk ratios so when you look at the risk ratios associated with all cause mortality and of course all CA mortality is the standard gold to think about life expectancy, we're going to talk about health in a moment, but we'll put this in brackets on life span, um, let's consider the known things that rob people of their lifetime, type two diabetes, high blood pressure, coronary artery disease, smoking, end-stage renal disease, those would be the most important, what are the risk indices associated with each of those conditions?

Well, at one end of the spectrum, you see hypertension has a hazard ratio of about 1.2, that's about a 20% increase in all-cause mortality, meaning you're 20% more likely to die in any given year than someone who is otherwise the same without hypertension smoking like I said is about 1.4 1.41 uh coronary artery disease about 1.3 type 2 diabetes about the same end stage renal disease about 2.75 somewhere between 1.75 and 2.75 so there's a 75 to 175% increase. , but now when you do the same analysis based on different metrics of cardiorespiratory strength and muscle mass the numbers are simply bigger and they are much bigger, for example, when we compare the V2 Max of someone in the bottom 25% of the population by their age and sex, that is, someone in the bottom quarter of their age and sex in terms of maximum oxygen consumption, which is a test that we can easily do in people, it is a measure of maximum aerobic capacity and is compared with someone in the top 2% of the same age and sex, the risk index is five, slightly above five. meaning it's a 400% difference in all-cause mortality;

In fact, if you go from being in the bottom 25th percentile to being slightly above the average 50th to 75th percentile, the difference in hazard ratio is 2.75, meaning it is even more significant than having a disease End-stage kidney disease. I could do this analysis all day long and I could do the same thing for muscle mass and I can do the same thing for strength, but overall the difference in all-cause mortality is significantly greater when it comes to measures of strength and physical condition. which is for any disease condition that we know of and that's why corals are all of this is, by definition, whatever you have to do to have that higher V2 Max, greater muscle mass and greater strength should be, without place Without a doubt, the most powerful thing we can do.

We have it at our disposal to live longer and, of course, the only way one can have those things is through the right type of exercise. Yeah, I really appreciate how you explained that, Peter, very, very clear. I definitely want to go into depth here, but let's clarify. A couple of things before we do, you mentioned health span and life span. I'm wondering if you could explain exactly what you mean by them and then I think it would be helpful to talk about your for Horsemen because I think it's a very beautiful concept for people. to understand the kind of core philosophy behind your approach, I think it would be very helpful to start here if okay, right, so the word longevity is kind of a shorthand word that people have a vague idea of ​​what it means. but it's also a word that's been largely bastardized by a sort of you know, a shady collection of people who prey on the fears of you know, people who are afraid of one of the scariest things we experience, which is the fear of dying, so, um, I I generally don't love the word longevity even though it's part of the subtitle of the book, but I use it because, again, it's a very obvious abbreviation for what we're talking about, but if we want To be more technical, we are really talking about longevity there are two vectors, one is the useful life vector and the other is the useful life vector.

Now the lifetime vector is the one you know the most, call it objective, easiest to understand digital binary, whatever word you want to use, it's either inside or outside of you. You are either alive or you are dead and there will certainly be some gray areas around brain death, but for the most part people have a clear understanding of what it means to breathe versus not breathe, so you know that your life ends when you die and at At least part of longevity is, on some level, extending lifespan, but I think unfortunately there's a bit of a Silicon Valley ethos around extending lifespan to, you know, magic numbers, we'll all live to be 150 or 200. and um.

You know, the reality is that I think that not only is implausible, but I don't think it's really what most people are interested in. I think what most people are interested in, even if they can't articulate it, is the other side of the equation, which is the health-span side, which is the part of quality of life to which I referred to earlier, this is the part where medicine 2.0 is failing dramatically, so not only is medicine 2.0 failing to add many years to life expectancy. It's already been done, but we're doing it at the expense of health duration, and health duration is harder to explain because it's more nuanced in the first place.

I think it has three components, but it's also analog, it's not binary, it's not on or off. It is relative and decreases slowly and noticeably and sometimes it decreases very quickly, for example, a person who suffers a devastating injury would experience a dramatic reduction in one of the three areas of health, which is the physical component of the body, the exoskeleton. There is also a cognitive part and an emotional part, and what makes all of this even more complicated is that two of those three depend a lot on age, the physical and the cognitive, while the third, the emotional segment, doesn't really depend much. of age, in fact, we sometimes become wiser with age to improve our emotional health.

I mean, we definitely get to emotional health, but I really appreciate that you explained how these four horsemen fit into this conversation about life expectancy versus life expectancy, so when you want to think about the life expectancy side of this . equation, it seems logical that one should have a great knowledge of what the impediments to life expectancy are; in other words, what takes our life away, and for a non-smoker, this can be summed up quite easily into the big four, and the big four are the diseases of atherosclerosis. so cardiovascular and cerebrovascular diseases are number one, followed by cancer, of course, as you and your audience know that cancer is not just a disease, you know that breast cancer is different from colon cancer, but in Overall, all cancer number three is a neurodegenerative disease. and related dementias, so neurodegenerative disease includes Alzheimer's disease, Louis body dementia, Parkinson's disease and also includes other types of dementia, such as vascular dementia, frontotemporal lobe.

Dimension things like that of that nature and then the fourth Horseman is not so much on the list because of the number of lives he takes directly, but because of the number of lives he takes indirectly and that's less of a disease and more of a spectrum that goes from insulin resistance and nonalcoholic fatty liver disease to type two diabetes. Basically, what we consider metabolic diseases, which again in terms of how often those diseases appear on the death certificate, the approximate cause of death is not that great, you know, we're talking in the United States, maybe around of 100,000.

I imagine in the UK it's a little bit less, but that's how those things amplify the risk of the other three Horsemen typically about twice as much, so what we really want to keep in mind is understanding that when you have type 2 diabetes, disease of non-alcoholic fatty liver, insulin. resistance, your risk of cancer, neurodegenerative diseases and heart disease increases significantly, so by understanding everything we can about the four horsemen we have the opportunity to delay their onset and that is really the goal here. I don't think we are in a situation that prevents science. fiction to completely eliminate horsemen certainly some of these diseases seem somewhat inevitable for our species. um cancer, for example, at the end of the day is ultimately a tug between acquired genetic mutations that alter cellular properties and our immune system's ability to detect them. and evade them um, but we can certainly delay them and we already have great evidence that that happens and the proof exists in long-lived people, the so-called centenarians who already live to the age of 100 years or more and we know this thanks to the study of these people . that their superpower is not to live more with the four horsemen, but to live more without the four horsemen, once they contract the same diseases as the rest of us, the time it takes for them to die is approximately the same, it is that they contractdiseases about two decades later than everyone else, yes, and that is what we have to discover, yes, super interesting, that is really something important for us referees to reflect on that these super centenarians, once they have the same problems that we, the time to death is quite similar, it's just trying to delay that, so going back to the problems with the medical system, the way it's set up, the way we're trained, the way many of us still practicing, we got involved very, very late, you know, we diagnosed type 2 diabetes in some places. theoretical point that we have defined for many years.

I've been teaching doctors in the UK saying, listen guys, we're still reporting in hba1c if we have slightly different limits than you, so we have 6.5 yes as the limit for type 2 diabetes, but here we call it prediabetes, eh , from 5.7, where I think you guys start at six, but anyway you know a lot of times we report these suboptimal blood sugar levels as normal and the way it works. In the NHS, usually here, the National Health Service, what will often happen is that they will draw your blood and often they will tell you that if you don't hear from us, everything is fine now, first of all, that doesn't It is satisfactory in several aspects. levels a is such a giant with a system things go wrong things get overlooked all the time so I would always tell my patients to call on the phone to make sure they have their result, make sure someone has said something about that result, but don't rely on the fact that there's nothing in the post, so you're fine, but the broader point is that even many doctors don't engage with their patients or take preventive measures until it's pretty far.

Advan, you know, type 2 diabetes, Alzheimer's, you know? dementia, for example, you know Dale Breson will say that that condition maybe starts in the brain, maybe 30 years before you actually get a diagnosis, for example, and from your perspective, Peter, I know you have a pretty personalized practice and very specific. Do you know what are the things that we should be looking out for, what are the things that we can all start looking at in ourselves to make sure that we're not waiting until these diseases have set in and we have an advanced end-stage disease, do you know what are?

These key things that we may be walking around with but aren't aware of certainly vary by disease, but let's take the clearest example of where prevention is unequivocally capable of getting us to the point where we would be much more likely to die. of an illness rather than because of it, and that is the ultimate goal. So you already know. I'm sure you've shared this with many of your male patients. I mean, any man who lives long enough will die of prostate cancer, but some will die. die from it, true, but most men don't die from it, they die with it, so the broadest example of that from a disease perspective is atherosclerosis.

Everyone has it, to some extent, the goal is not to die as a result of it. die from a major adverse cardiac event, a heart attack, a stroke, so what would it take to delay the onset of atherosclerosis? Something that, in my opinion, is probably inevitable for our species. Well, again, this is where understanding your opponent matters. Now it turns out it's a heart disease. atherosclerosis we have a great understanding of its pathogenesis and we know that while genes play an important role, those genes play an important role often through modification of the following pathways Lipid-related pathways Blood pressure-related pathways Blood pressure-related pathways endothelial dysfunction Pathways related to endothelial dysfunction So what are the big risks? for heart disease smoking high apob high blood pressure and metabolic disorders so the most extreme example is type two diabetes but again any glucose and insulin dysregulation will amplify the risk of type two diabetes forgive me for cardiovascular disease So how can we take it? that information and act accordingly to delay its appearance by two decades.

Well this comes down to how you see the world through the lens of prevention, so I can't speak to how it's done in the UK, but I can tell you that in the US we tend to see things through a time horizon of approximately 5 to 10 years, so we use risk calculators. Risk calculators incorporate information like your family history, whether or not you smoke, what your lipids look like, your blood pressure, things of that nature. sometimes they even incorporate information like a calcium score and spit out probabilities. They say that the probability that you will have a major adverse cardiac event, so death from heart attack and stroke in the next 5 years or in the next 10 years is x% and the consensus opinion here in the United States is not It is necessary to treat a patient for primary prevention unless that number is above a threshold typically 5%, so if you are talking to a 39-year-old patient, by definition, it is mathematically impossible for them to have a risk to five or ten years higher than 5 percent.

In fact, most risk models do not even allow a calculation if the age is less than 40 years, in my case that was the case. I started paying attention to this 15 years ago, when I was 35, and there were no risk models, so basically no. one would consider having treated me preventatively even though my family history was significant. I even had a calcium spec on my calcium score, which is a symbol of late-onset atherosclerosis. My opinion is that this is completely backwards logic. It is backwards for two reasons, the first is the time horizon is completely wrong, yes it is true that if a person's 10 year risk is high we should act dramatically, but wait until a person's 10 year risk be high is equivalent to driving a car towards the edge of the cliff and telling the driver that you are only allowed to hit the brakes when you actually see the edge of the cliff, yeah, instead of telling the driver that I can't see the edge of the cliff now , but I know there is an edge there, let's slow the car down, but the second This reason for me is even more frustrating and I think if I am going to be critical of the medical establishment in one aspect, it will be this: they often don't appreciate what implicit causality and causality is a complicated topic because it is often confused with correlation and association, but I will spare The Listener all the details because I write about it at some length but there is no ambiguity about the causality of apob and its effect on the atherosclerosis.

I don't know how familiar your listeners are with apob and if it's worth explaining what it is, but yeah. Q. I was going to ask you, so please expand on that because it's not a test that the NHS does either. offer to people in the UK, so not only is it, I know very well, a very powerful predictor, if not the most powerful, but at the same time it is something that people, unless they pay private here, which is a very different model, they don't really have access. So, yes, please explain. Well, the good news is, first of all, it is a very affordable test even in the United States with our wildly high and disgusting costs that are artificially inflated.

Even in the United States, the APOB test is only on the order of about 20, between 12 and 25 dollars, so I imagine that in the United Kingdom, even if one were to pay out of pocket, we are talking about a test that would probably cost less from what you know, 10 pounds, but that being said Leaving aside for a moment, um, the substitute for apob for a poor man, which I assume the NHS would cover, would be non-HDL cholesterol, yes, it is something that would be readily available to anyone, yes, so non-HDL cholesterol is a poor man's substitute for apob, but what? apob is a protein that surrounds all the particles that cause atherosclerosis, of which the most common is low-density lipoprotein or LDL, and by measuring the concentration of apob, the concentration is directly measured, that is, the number of particles per unit of volume of all lipoproteins the ldls the vldls idls lpas that cause atherosclerosis and that turn out to be the most powerful predictor of any lipid or lipoprotein when it comes to cardiovascular disease and what we want is for that number to be as low as possible in Formal logic, we would describe apob as necessary but not sufficient for atherosclerosis, so it is necessary to get atherosclerosis, but by itself it is not sufficient to cause atherosclerosis, meaning that there are some people with very high levels of apob who They do not develop atherosclerosis. but you cannot get atherosclerosis without it, that is why we have established it through epidemiological studies, primary prevention studies, that is, the treatment of people who do not yet have cardiovascular diseases, secondary prevention studies, the treatment of people with diseases cardiovascular and Mandelian randomization, perhaps the most powerful.

We can all explain that if people want at one point but I don't think it's Germain, we have established through all these different levels of evidence that low-density lipoprotein or apob is causally related to atherosclerosis, this is very important again. , no I don't think there are many doctors worth their salt who wouldn't recognize that, so now the question is why wouldn't we dramatically reduce the level of this lipoprotein at a young age. I would use an example that I have used before, I think. I say it in the book on smoking, everyone knows that smoking is causally related to lung cancer, which means that it is not just an association that we see a ten times higher prevalence of lung cancer in smokers and, therefore, True, it doesn't mean that all smokers will get lung cancer or every person who has lung cancer was a smoker, neither of those things are true, but neither of those things diminishes the causal relationship between smoking and lung cancer and since we know that Smoking is causally related to lung cancer, we take a very simple preventive measure. strategy that consists of telling people from the beginning not to smoke and, if they smoke, to stop smoking immediately.

Can you imagine if we used models to predict the probability of people getting lung cancer and waited until the probability of that event was 10%? and then he says well, listen Johnny, your risk of lung cancer is now 10%, it's time to stop or let's wait until on the chest CT we see calcified lesions in your lungs that are suspicious for cancer, now is the time to stop, of course, not once we have established causality, eliminated the causative agent, and yet we do not take that approach in the treatment of atherosclerosis, which is why atherosclerosis is the leading cause of death worldwide. world. 19 million people die each year from atherosclerosis.

The second is a distant second cancer, 11 to 12 million per year atherosclerosis not only should not be the leading cause of death, it should not even be in the top 10 based on the tools we have to significantly delay its onset. Yes, I really appreciate the smoking analogy. I think it does. It really is clear how retrograde, myopic, frustrating and limited our current approach to how we view these things is. What's really interesting is you mentioned APO B and it's necessary but not sufficient in and of itself, of course, there's all kinds of other things, I guess, inflammation. immune dysfunction all kinds of ingredients to put into the mix that can really screw things up and end up having atherosclerosis, but you also mentioned that you want to reduce apop as much as possible, the lower the better, now what's interesting?

About that for me, when I hear that most things in life, I would say there are advantages and disadvantages, and often we just look at the advantages and deny them or don't take into consideration what the disadvantage is here, so let's say. APO b um, let's say we've measured it and it's higher than we would like and let's say the patient is reasonably high risk. I guess you would say that, by definition, having a high apob puts you in a risk category, the question then is how aggressively do you decide to lower it? What therapeutic intervention do you use to bring it down and then just add in there?

Peter, we're talking about these four horsemen who end up ending lives. Early right atherosclerosis. Cancer. Neurodegenerative disease. and I think poor metabolic health is true, it's always a scenario where you're aggressively attacking one rider to knock your wrist off of that one, which then inadvertently increases your risk of suffering from one of the other riders, yeah , there is and I think if we stick to this example, I think let's use two, let's use two examples correctly, so we know that aggressively using an agent classLipid-lowering drugs called statins have a small but non-zero risk of increasing insulin resistance in some individuals; in other words, there are some people who, when you give them a Statin, then a dose like ruva statin, atorvastatin, things like that, reduces their r o, which is the desired result, but you get an undesirable side effect, which is that glucose and insulin levels increase and are now pushing them further toward the risk side of the spectrum.

On the level of metabolic health, well that's a problem, because to your point, if you're solving one problem and creating another, that's a suboptimal solution, so we have to look for optimal solutions now, the good news is that where we are today. We have so many tools to reduce apob that don't come with those side effects. Now the good news is that most people and it's hard to quantify this, but it seems to be in the neighborhood of about 90 to 94% of people don't have any measurable discernible subjective. u objective side effects of statins, meaning they don't have muscle pain, they don't experience elevations in transaminases, they don't have insulin sensitivity issues or anything, but let's say 10% of people have pcsk9 inhibitors, we have aetam.

Bendic Acid These are medications that really don't seem to have any side effects. Sometimes when I look at the mechanism of action of a statin, I'm surprised that the side effects aren't greater because of where it works. inhibition of cholesterol synthesis and how it does it ubiquitously in the body, but when you look at how these other medications work, I don't think it's necessary to get into the mechanisms of each of them. I cover it very briefly in the book. It's intuitive that the mechanism of action of those drugs matches the clinical experience, which is basically that virtually no one has side effects with these other drugs, they are much cleaner drugs than a statin, if we can use that jargon, then, yes, the objective is to get approved. as low as possible, we'll talk about how low that is, but you have to be able to do it without creating another problem and I think 15 years ago, 20 years ago, that was a much more difficult proposition than it is today, before go further just on that point, which I think is a beautiful illustration of some of the kinds of advantages and disadvantages that have to be weighed if we step away from pharmaceutical medication for a moment and look at these four horsemen and go.

Well, what do we know that's probably playing a role in all of them? Most of them, unresolved chronic inflammation would probably be something that most people would agree is one of those root causes that will increase the likelihood of each of those four. So if we can adopt a certain lifestyle. Behavior is what helps us reduce chronic inflammation, so those lifestyle changes are likely to begin to aggressively reduce our risk of all four, we probably don't have to weigh, you know? reduce the risk of one and increase the risk of another. First of all, I wonder if you agree with that perspective or if you have a slightly different perspective and then from there, it is typical that only when we bring in foreign agents, let's say a pharmaceutical drug that these considerations of you know that it improves it here problem here starts to become a problem because you mentioned statins and of course some statins are known to negatively impair mitochondrial function and then you write about Bally in the exercise section of the book about the importance of mitochondrial function for a big variety of different reasons that hopefully we'll get into during this conversation, so it's these pros, cons, cons, that come up for a lot of people if they listen to this and try to take ownership of their health and I know your book will help them. guide them through this and try to figure out how they do it.

It might seem like, as a man, it's that confusing, am I going to reduce my risk of atherosclerosis but at the same time increase it? my risk of type 2 diabetes, so how would it help us? How would you help the general public who know see these issues and what they can practically do to control this risk themselves, if anything? Okay, so I think the first question was: the whack-a-mole problem, where you reduce the risk of one only to potentially amplify the risk of another, is a problem that we only see in pharmaceuticals and the answer unfortunately is no, in fact. that's a general life problem, there is no scenario that I know of whereby you can take an action that addresses one problem that doesn't potentially have an impact on another, so let's take two lifestyle examples, in quotes, examples of lifestyles where you have a clear positive impact in one area and a clear negative impact in another uh, the first one would be fasting, okay or let's be more, you know, let's talk about calorie restriction, extreme calorie restriction, so that there are only two interventions in the entire geroscience literature that have reproducibly extended life spans in virtually all the model organisms in which they have been tested.

One of them is caloric restriction when an organism's calories are restricted in a laboratory environment. They generally live longer. There are some caveats, but as a general rule calories are restricted in mice. Rodents, flies, worms, everything, they just tend to live longer. We believe that calories restrict humans to 30% of their required caloric intake, so a person who would normally need to eat 2500 calories per day, will eliminate 30% of those calories per day. Every day we believe that that is a net benefit in their lives and the answer is that it probably isn't, because while you will certainly have reduced your risk of diabetes and metabolic diseases and probably, by extension, you will have reduced your risk of cancer and such. instead of heart disease.

The disease process is less clear on the neurodegenerative side certainly, certainly, and this has been shown in animal models, increased susceptibility to trauma and infectious diseases. In fact, those people are very likely to end up with a case of sarcopenia. much more susceptible to one of the other great Horsemen who does not reach the level of being the big four, but is very close to number five and that is accidental death, which is practically dominated by falls once the age of 65 is reached . so these are individuals who lack muscle mass, who lack bone mineral density and the mortality from a hip fracture or a pelvic fracture of the FL when you reach the age of 65 is close to 30% in the first 12 months, yes, so , if you solve one problem, you create another and that is Again, we are simply dealing with something that is potentially as beneficial as the choric constraint.

Let's take another example, if an individual goes from never exercising to exercising at an extreme level, he could get injured, so he will get many cardiovascular and muscular benefits. of exercise, let's say they adopt a very aggressive regimen where, you know, they run an hour a day and lift weights for two hours a day, that has a huge benefit, but if they themselves and I mean a serious injury, you know that harm. a disc in their back that ultimately requires a double fusion that will have a terrible outcome on the length of their life, not necessarily in terms of how long it is, but in terms of the quality of life and the pain they suffer, as well I just want to make sure that everyone understands that everything we are talking about has its advantages and that is why we have to be nuanced and apply the appropriate tool at all times. the right time and I think what you know, what I tend to get angry about is the idea that individually or collectively we would view tools as binary, good or bad, yeah, right, you know, and I get this question all the time, of course. .

Surely you know, which statins are good or bad? Do you know if metformin is good or bad? And it's like that's the wrong question. It's like asking a carpenter. Is a hammer good or bad? Is a screwdriver good or bad? It depends on what you want. you're using it and it depends on whether you know how to use it, you know, if you try to take a hammer to a Phillips screw, that's a suboptimal use case, if you try to take a Phillips screwdriver to a nail, that's a suboptimal use case, so we, yes, we have to move away from what I call painting by numbers and adopt sophisticated and nuanced approaches to pharmacology, exercise, nutrition, sleep, etc., which qualifies a strength, right?

The reason I asked that question is because, let's see, you're a runner, right, and I. I personally think running is fantastic, it's a very innate human movement, you're loading your um, you know you're interacting with the ground, you're putting load through your joints through your tendons, if you're doing heels, it'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 this, you'll repeat regularly, that qualifies as strength training, probably not because it's still a number of reps high enough to not hit the type two muscle.

The fibers are fine, um, as evidenced and by the way, even when I'm walking uphill with 100 pounds on my back at a 15% incline, I'm still doing so many reps that I'm primarily fatiguing my type 1 fibers. even though you're the one moving your body weight against gravity, which is a form of weight and doesn't meet the threshold to work on that particular T fiber that we're going to need when we're at 70 or 80 coming off a sidewalk. right, then a better example would be to do a box step with weight in your hands, you know, if that were the case, get a box, hit it up and down, up and down, holding the weight in your hands and, if you you could do that is such that you could literally, you know, so we usually talk about doing these sets until you have one or two reps in reserve so that you don't have to fail when you're lifting, but you want to do it until you could only do one or two. reps any more and that would be a failure and if you're loaded to the point where you're doing eight to 20 reps but you meet that criteria, your one or two reps in Reserve as max definition, you're now recruiting type two muscle fibers that you've fatigued throughout type one and type two so as a runner you'll appreciate the difference in how that burn feels versus the burn of running hill repeats again there's a lot of benefits to running hill repeats um and you're putting in try your V2 Max and you're doing a bunch of other things um and by the way, as a racer you will benefit from the power that comes from those CLS boxes okay, it's fascinating, so that was a component, so it will repeat, it doesn't count, you're looking at something that's just one or two away from your maximum, which I think is very helpful, very, very specific to people and again in terms of making this accessible to people, that's relatively, already you know, step up, you know, it's like 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 it you can do this in any hotel you can do this in any it doesn't have to be a super fancy gym, you know, carrying weights, doing what's called a farmer, carrying such an important form of activity, both for your grip, like that that most people will find when they do this initially and we have standards for our patients when it comes to these types of exercises, whether it's box step UPS um Farmers carry, you know, for example, for a woman, we want her ultimately , uh, and we index this by decade. but let's say that a woman in her 40s should be able to carry 75% of her body weight in her hands for one minute, so if she weighs 100 PB she should be able to carry 75 pounds 37 and a half in each hand for one minute and if she can do that I can if she can then she means we're pretty sure that when she's in her twilight years she'll have the strength to open a jar, for example, do all the things that we think she really cares about. people, 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 herself and see what I can wear now if they can't, let's say they're going well, this sounds great, oh wow, I can only do it. 20% or 30% or I can only charge it for 20 seconds and then my grip fades, yeah, so what's the advice?

So it means dropping the weight, so let's say go to half her body weight until you can get to a minute, look for a weight. that you can get to one minute and then slowly advance the weight, that's brilliant, really practical and for a man it's your body weight for one minute, so at what age again in your four in your fifth decade, between the age of 40 and 5050? For example, if the man weighs 180 PBS, he should be able to hold 90 PBS in each hand and walk for one minute. Yeah, I love that and again, a lot of people won't be able to do that right off the bat.

Okay, drop it. Ohat 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 never have done it as a kid, they may be intimidated by gyms . I don't know what to do and I'm like, ah man, I can't afford a personal trainer, I don't know what I'm doing, farmers wear this, it's kind of like you know, I guess you have to keep in mind that you're not staying. you're clear in your head 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, sure and we have, um, I don't remember if we included the farmers in the video in the book, but there is a series of videos that we made to accompany the book. It's on their website. at least half a dozen exercises, including the step by step, where we show the correct form because you're right, you can cheat, you can do these things incorrectly, there are many ways to do it and we always have people starting these things. with just body weight, for example, in the step, you know before moving to any weight, maintaining strength, let's talk about the grip strength and the strength of the feet, the extremities of our body, why are they so important?

Maybe there is a lot of data on grip strength, yes, but what is fascinating to me and you will explain the DAT to me. I'm confident about the grip strength, but that might tell someone that I need to strengthen my grip, so I'm going to go shopping with those little grip grips with those little grip grips and just get a really really strong grip, which I'm not totally convinced it's going to do what we want so maybe expand that if you can yeah so I think the same reason why V2 Max is such a remarkable proxy for lifespan and health span it's the reason why grip strength always seems to be a notable indicator for both as well and it all comes down to what they are indicators or what I like to describe as integral so you know what, at least in theory, a hemoglobin A1c is supposed to be. to be an integral or sum of how your blood glucose level has been over the last three months.

Similarly, a very high V2 Max is an integral of very hard training over a long period of time, yes, if you took an out of shape person and said, "I love you." to train very hard for a week, they will not have a high VO2 max in a week; In fact, if you take a person in the bottom fifth percentile and make them exercise for three months, they won't make it to the top. fifth percentile, that's why you can say that a person in the top 5% of V2 Max has years of training, that's what it tells you, so it's a very good predictor of life expectancy because it reflects much more than we can obtain from a questionnaire. me, how much exercise do you do a week and how strenuous it is, who cares, as if all those contributions are reflected, it is total and cannot be hidden, cannot be masked, cannot be deceived, yes, the same thing happens with grip strength.

Strength is an integral part of overall strength, you can't be very strong without having a strong grip, so I think about being in a gym and lifting weights, you're always using your hands. I'm here in London at the moment. At a hotel I was doing deadlifts yesterday and sometimes I bring liquid chalk with me because you know, if you're at a gym and they don't like you using chalk, you have this liquid chalk and I forgot to bring my liquid chalk and so on. I had to deadlift without chalk yesterday and it's just a stark reminder of how I limit my grip when deadlifting;

In other words, I was failing because I couldn't even hold the bar anymore, so 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 great Part of what I do in the gym is driven by my grip strength, yes, when I'm doing a pull. 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 use your grip a lot when you strength train, so it's true that it's something easy to measure. and that is also true with V2 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 no matter where you are you can always measure this same thing is true with grip strength leg extension chest press I mean , these are the things they normally measure, but you know you'll always see studies talking about grip strength and I completely agree with you that it's a little misleading because people think Great, I just need to go get a little juicer and it's like no, definitely don't get a small juicer.

Go pick up heavy things and walk. Yes, there is something about the limbs thing. Isn't that how we interact and carry things? but our feet are how we interact and that is that these are the hands and the feet are the transmission of the Force to the outside world, yes, I was going to say biases, but yes, I was trying to be aware of my own biases, I personally have been wearing minimalist shoes for over 10 years now and they have been transformative for me. I have recommended them to many patients over the years, not all, but many of them, and have heard and seen many improvements now again.

Be careful, I'm not talking about going from wearing cushioned shoes your whole life to suddenly trying to run marathons in your minimalist years. No, no, let's be logical, let's be rational about this, but I'm wondering what your perspective is on foot strength and how it relates. what you just said about grip strength and potentially where minimalist and barefoot shoes might fit into this part of the conversation. Yeah, I mean, I have the luxury of because I work out at home. I exercise barefoot, so I really enjoy being barefoot. as much as possible um and I think um look feet are very similar to hands um in terms of musculature what I think most people would appreciate is that we have a lot more dexterity with our hands than we do with our feet and um a part That's the fact that our hands are never really restricted like our feet are, so when we wear tight shoes constantly, in other words, it's not just about wearing a minimalist shoe versus a non-minimalist shoe, it's like having your toes of the feet together pointed toes yes, you know, 12 hours a day, that creates a difficulty in using the foot the way it was intended to be used, so for people who have children, look at your children's feet Yes, you see what happens, yes.

So, anyway, that's a long way to say: I completely agree. I think the shoe industry has probably gotten to a place where we're not making healthy feet and a lot of people, myself included, have had to spend a lot of time undoing the damage of wearing shoes too often and very tight shoes and you know, interesting, There was a study done at the University of Liverpool a couple of years ago and to be fair this study was done using five barefit. shoes and to be completely transparent, they are one of the supporters of the program and made it clear to me that I was purchasing them with my own money for seven years before they started sponsoring the program.

That being said, that study showed that adults who were wearing these minimalist shoes for four to six months just for regular activities, for work, for shopping, for walking, not for running or not for going to the gym, just for get on with your day. I think, as I remember, the strength of the foot decreased. increased by over 60%, which I found notable because you're not actively trying to exercise your feet, you're just wearing something that allows your feet to have to work harder than when they're fully cushioned. yeah which is pretty amazing so strength I just wanted before I move on from strength just touch women there are some unique pressures on women especially postmenopausal so I just want you to be able to talk about that when We talk about strengthtraining, yes, it is very important for both men and women, but, in your opinion, are there particular reasons why women should pay special attention?

Part of it, I mean, there are several, but part of it I think is that on average, women come, for example, to our practice or to you. I know that in middle-aged adults, in middle age, they have done less strength training than men. Of course, we use nomograms that are sex-specific, so when we look at muscle mass metrics we use something called the appendicular lean mass and fat index. free mass index so they will normalize for age and sex but you know women often come in with less strength training so they will have less muscle mass that's a problem yeah yeah strength and muscle mass are positively associated with life expectancy and health for men and women alike and, um, there's a big step up once you're in the 75th percentile, so, in other words , the top 25% compared to the bottom 25% for muscle mass is a pretty significant difference.

In terms of all-cause mortality risk, okay, let's imagine two scenarios: a teenager or a father listening and worrying about his daughter, let's say maybe also her son, who is a teenager we've talked a lot about . the decline that occurs in your 30s and 40s, there are things we can and should do with our children with teenagers to further isolate them, oh, yes you are from this decline absolutely and I'm glad you brought that up because, um bone density. mineral has a strong genetic component. However, you achieve your genetic cessation or your genetic potential at age 20, 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 as a teenager by the time you are 20 years old, you will not reach your genetic ceiling and everyone, both men and women, are in a state of decreased bone mineral density from the start . until your mid-20s for the rest of your life, so if you're before that, if you're listening right now and you're a teenager or if you're a parent, we should do everything we can to encourage our kids or yourself, yeah Are you that teenager who will be lifting heavy weights until at least 22 23 much longer, 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 approximately in the mid-20s?

Thereafter, women have a much more precipitous decline than men, if they do not follow hormone replacement therapy, so estrogen is the most important hormone for bone health in both men and women, and women lose their estrogen rushes in around age 50 if you don't take HRT, then in that sense women are more susceptible and it is not uncommon to see women in the menopause transition who have not been lifting weights even if they have been in very good shape and have been working out. Showing up with osteopenia, uh, wow, and I mean, we see this too often.

There are 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 a new kettlebell delivery occurs. I come home and I have them lying around and the kids pick them up and play with them and my wife says, "No, no, leave it, you'll get hurt." injuries to consider you have to be safe, but I think you know what kind of let them choose well, it's funny to say I mean my two kids who have uh one just turned six and the other one is eight, they really got interested in coming to the gym with me last year and, um, I just started doing kettlebell lifts, so it's a deadlift basically with a kettlebell, so they're standing on a kettlebell and you know, at first I just Los I had doing it with the lighter kettlebells and they were getting really upset and really wanted to start lifting heavy things, so I said, "Okay, guys, as long as you can listen to me and you can do this correctly, and it actually worked out." ".

It's really challenging to tell a five and six year old to deadlift because I can't tell him the way I would tell you, yeah, I can't tell him about intra-abdominal pressure and thoracic extension and all that stuff has to be. much simpler, so the first thing I realized when I saw him pick it up was that he was doing it incorrectly and I was surprised to think that a child would always pick something up correctly, but he didn't, he was using his back and not his legs and I thought why what's 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 have deep tension in your arms, you can't use your legs if you don't.

He had some tension laxity in his upper body and 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 cue him correctly. but then to see howThey perfectly can lift things, um and now it's fine, so you just come to the gym and all you want to do is lift that kettlebell up and down, up and down, up and down, how old are you? He turned six a couple of weeks ago I love it, yes I love it and obviously he wants to do what daddy does and lift things.

I want to, I want to do that as well so that we can potentially take advantage of that, yeah, um, but the point is that this is like that. important for teenagers and again you may have mentioned something before that I think is a worrying and disturbing statistic and that is you know over any period of time, I can't remember 30 years, I think you said there was 90% Loss of 90 seconds in a mile, you know, unfortunately, I'm sure there was a comparable statistic for strength loss as well, so basically with kids and teenagers we want to encourage this early, of course, the same goes for fitness in others. words you like.

I feel very lucky to know that although I don't train at a fraction of the level I used to, I think part of the reason I can maintain a relatively high level of fitness is that I maintained an absurd level of fitness as a teenager and I was 20, 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 anyone who reaches 50 and is out of shape should be discouraged. You, in many ways, they have more potential, they have potential to be taller than they were before.

I don't. I will never be as tall as before. um, but I'll probably be taller than that person because of the fact. who 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 your kids are in shape, of course, one of the four horsemen is Metabolic Health, so maybe Maybe we could talk to you briefly. Metabolic health, what is it and why do you think a CGM, a continuous glucose monitor, is potentially more useful to us than the standard market that we have, for example, hba1c, which is two for average blood sugar measurement of three months that a lot of people have easy access to, yeah, so I'm going to guess that your listeners know what a CGM is, it's a device that you wear, it's implanted in you, it has a little filament that is REM like there's a needle that you insert a filament, the needle comes out but the filament stays in and it stays in, you know, basically the subcutaneous tissue and it samples interstitial fluids, so it doesn't actually measure blood glucose level directly. but it does it indirectly by measuring the level of glucose in the interstitial fluid of the subcutaneous tissue and it is calibrated to then know how that translates into glucose, so if it is working well and that is important, if it is giving you the real time, maybe be delayed.

With a five-minute reading of your blood glucose, why is it so important? Well, I think first of all, it's important for patients to understand how various factors affect their blood glucose and the reason for that again comes down to understanding the relationship between average blood glucose and gluc because variability and health and at the extreme levels this is not discussed in other words, I have yet to meet a person who has tried to discuss that, which is not to say that someone isn't trying to discuss that, but I certainly haven't. met the person or read the argument that type 2 diabetes is harmful, in other words, that when a person's blood sugar averages more than 140 milligrams per deciliter, which is the limit of 6 .5%, a hemoglobin A1c is produced that represents a greater risk to an individual relative to a lower hemoglobin A1c that is outside the diabetic range, so the question then becomes: what happens if it is not talked about at all? through the lens of type two diabetes?

So if you were to take a hemoglobin A1c of 5.7% or 5.6%, which would translate to about 120 milligrams per deciliter in our units uh, that's probably about six Mill in your units, right, um and then the question is how does that compare to a hemoglobin A1c of 5%, so now we're talking about two people who don't have diabetes or type two or prediabetes and we're wondering how do you compare two, quote unquote, normal blood glucose levels when one is higher than the other one, let's say 120 and the other one is 100, well, it turns out that analysis has been done, we have written about that and the analysis is pretty clear that there is a monotonic decrease in all-cause mortality as average blood glucose decreases even within the normal range outside of type 2 diabetes.

Similar analysis exists for other glucose parameters, so the bottom line here is that things that can result in lower average glucose in blood even in the normal range, that is, below the threshold for type 2 diabetes, are probably beneficial for all-cause mortality and therefore measuring those things using a hemoglobin A1c would be the crudest way to do it. one advantage of measuring that, in other words, I would say to a patient whose hemoglobin A1c is 5.6, let's work to get it down to 5.2, even though both patients are considered normal and I can say Pizer, just that, I just want to highlight For the People, that's what you just laid out for me, it's one of the big holes in the way we practice medicine today, it's normal but not optimal, it's the lack of recognition that these things are on a continuum. and we don't want to wait until it's too late, we want to get involved early, so please continue.

I think this is a very important point for all of us to understand. No, thanks for making that point. It's actually a A more eloquent way of saying what I was trying to say is that we tend to confuse normal and optimal and that they shouldn't be normal is generally a term that is reserved for being within the extremes of a bell curve, so if something is normally distributed on a bell curve, we could say that you are normal if you are above the 5th percentile and below the 95th percentile. You know that 90% of the people who are not at the extremes are, in quotes , normal, but that doesn't say anything about being optimal and this.

This is true with blood glucose. This is true with kidney function. This is true with the apob. This is true with liver function tests. The transaminases. It's true with hormones. It's true with everything. So CGM is a tool that offers at least a couple of advantages over what I would offer. To be clear, let's say three advantages over measuring something using a hemoglobin A1c. The first is that hemoglobin A1c tends to be inaccurate in any scenario where the lifespan of the red blood cells is not exactly as predicted by the assay, so you know, so people understand hemoglobin A1c.

It is something that is measured directly, the blood is drawn, the amount of glycosylation in the hemoglobin molecule is measured, that is the number that is obtained, it is 6.1% or 5.7%, the average glucose in blood is imputed, not measured, it is imputed from hemoglobin A1c based on a belief that the red blood cell lived for about 90 days, but if that red blood cell was in circulation for a much shorter period of time, for For example, in a person with low-grade anemia, whether due to red blood cell turnover or bleeding, they will bleed low-grade. to get an artificially low estimate of your average blood glucose because the red blood cell has not been in circulation long enough to accumulate glycosylation, so if it goes back to 5.0 and your average blood glucose is assumed to be 100 you are massively underestimating it, similarly, conditions that lead to you would also see this, by the way, in macroanemia and things like that, you would also see the opposite in conditions where red blood cells stay longer, so microtic conditions like the betaal trait and things of that nature that result in small red blood cells that are not chewed up at the same rate through the spleen, you will see a longer residence time of the red blood cells, you will see artificially elevated estimates of hemoglobin A1c. or average blood glucose Vis hemoglobin A1c, so that's the first reason I calibrate a CGM and I insist on calibrating them when I use them.

I don't trust the manufacturer's calibration, so I insist on doing calibrations all the time I would use a CGM. Calibrated CGM is a much more accurate tool for measuring average blood glucose and glucose variability. The second reason is that the person who wears it, even if they only wear it for a month and never put it on again, gets a much deeper relationship or perceptual relationship with how various factors, particularly what they eat, how sleep, how they exercise, and what stress is, they can see how those things affect blood glucose and that's what they know, having used a CGM on myself and with patients going back eight years. it's just that I have yet to meet a person who isn't surprised the first time they use one in those relationships, yeah wow, I didn't realize how eating at night is different from eating in the morning, like eating after working out is different than eating when I don't exercise, how sleeping six hours a night changes my blood sugar the next day vs sleeping eight hours a night how being under stress vs not being under stress I mean, the differences are so pronounced that people are really impressed so there is this phase of what I call knowledge generation so there is no substitute and it can't be done without real time feedback and then the final reason and this is more for people like me who find value in the use of this tool beyond the state of knowledge, it becomes a behavioral tool.

Yeah, if I'm using a CGM and I go to my pantry and I see a bag of my favorite junk food, I'm less likely to consume it when I use the CGM, there's just a gamification that happens with me where H I don't want the number to go up. I don't want the number to skyrocket because I ate five cookies, so I'll be better about not eating those cookies, and for some people, that's not the case. It doesn't mean anything that they don't need to, maybe have the willpower to, avoid those five cookies without the CGM, but for many people it's a valuable tool.

Those who oppose the use of CGM will often say that it could promote eating disorders or unhealthy eating. related to food and of course for some people it might be yes. I agree, I completely agree with that. I think we are very careful about who we prescribe CGM to and if a person has any history of eating disorders and we have patients in our practice, who does it, we just don't use CGM as a tool and we are very careful about other things as well, like monitoring from macr, yes, you know, yes, of course, this is an example of nuances that, again, I think.

At this point in the podcast, the listener understands that if there is something that has to support everything you are doing in medicine 3.0, it is Nuance, yes, for sure, so you must take into account who you are applying the treatment to. I am currently on my journey with MCG. I would say I wear one for two weeks every three months. I found that for me it seems to work pretty well. I get some ideas. Then I don't use it, apply those ideas, and then put it back in a few months later to see where I'm at.

You can help me modify it frequently if I have fallen. It helps me focus, but that's what works for me and I'm sure for some people too. For some people it will be less, it could be more, and of course for some people it may never be, but I have yet to see anything more powerful in two decades of practice, as you just highlighted in behavior change. We've mentioned blood pressure and it was really interesting for me to watch your journey and read your book about when you found emotional health to be a key part of the Health and Longevity conversation and I feel that emotional health to me because of the struggles that I've had. personally but also to patience.

I don't know if this rings true for you or not, Peter, but I always used to watch people and people said that information is power. It's good, awesome. I don't disagree with that statement, but what I see is that patients would make changes. together we would help them make some changes in their lifestyle, you know, that term lifestyle, their life, their life behaviors, let's say, and they would start to feel better and sometimes that would be 1 month, sometimes it would be They would do it for four months or 6 months and their life would be transformed and they would feel good, they would have energy, they would have better relationships, they would sleep better, whatever it was, but often people would go back to where they were before and I would observe this with patients and I would think Okay, why this?

Clearly it is not an information problem. They know the information. They don't just know the information they experienced. You can feel when you apply these things. Why are they coming back now? Of course, there are many different reasons, but this. The kind of topic I covered in my last book was that I thought lifestyle is really the problem here or is it something else?ascending and I've really come to the conclusion that it's actually something more ascending than that, it's the way they approach the world. It's how they handle conflict, it's how they handle their relationships because when there are issues with, let's say, emotional health and I think the chapter you've written is brilliant.

I think often our lifestyle choices are downstream consequences of them, so one of the reasons I went down this path maybe 5 or 10 years ago is because I thought no, I needed to address this. Sorry too, Peter, sorry for the long start up to this point, but I'm trying to make a couple of points. It seems to me that during your return to Medicine you have had access to a lot of testing, so you can do a lot of testing on your patients for whatever reason, compared to someone who has typically spent most of their career in the NHS.

The fact that the service hasn't had access to the evidence means that I feel like I've really had to pay attention to other things, so I don't have the evidence, so what is going on here or are these words being said to me, which one? is the story behind his words? So I feel like maybe the different ways we practiced meant we came at this from slightly different approaches, so a couple of things, Peter. I'm wondering if you could give me your perspective on what I just said. I don't think so. what you said is beautiful um and I think it's an amazing way to think about the differences between the two extremes of the opposite extremes or extremes of um how do you know we could talk about two different practices so I'm sitting here in the United States. , which is private health insurance, but there is no national health insurance and even within private insurance you know that you can go from insurance to just a fee for service and you know that the United States is kind of heaven. the limit when it comes to testing testing testing we can do anything right, you're on the other end of that spectrum and yet you're absolutely right.

I think our system pays very little attention to the problem you address and I think you are very astute and would be curious to know what fraction of doctors within the NHS would recognize what you have recognised. I mean, I have less at my disposal right now in terms of sophisticated tools, so I'm going to rely on more of these human tools, these interpersonal tools, these skills that once made a doctor what a doctor was and I'm going to relying on them to try to better understand how I apply the fewer tools that I have, so no, I think I think that's really interesting, of course, you know, my foray into this as an interest was very personal, it started through my own experience, and I would say that before my own experience with this I wasn't necessarily as attentive to how much. of a struggle that perhaps others had and what role this played in other people's behavior, especially in the examples that you use around you, you know the ability to make changes and then the ability to sustain changes that you have shared very openly in the book. but also in some of the podcasts that you've already done, you know you've really opened up about some very, very personal things in your life, parenting things with your wife, um, your son was sick when you were, I think, in New York. . and it's really interesting.

I've been listening to them in preparation for our pizza conversation, and I know that you do, and I think you've admitted it, have perfectionist tendencies, or certainly have for a long time. of your life, I'm really interested to know what it's been like for you as someone who for a lot of your life I think has at least seen you as a perfectionist being on these big platforms, these big global platforms and now being really quite vulnerable. by sharing. Things about yourself that potentially an earlier version of you maybe wouldn't have admitted to yourself and certainly wouldn't have shared with hundreds of thousands of people.

What was that experience like for you? Have you reflected afterwards? Have you thought after these conversations? Oh man, did I say that too? Very similar to what it has been like for you on a human level, well, it is very uncomfortable. I mean, I don't think, I appreciate that you think maybe I'm a former perfectionist. I think I'm a recovering perfectionist. and uh, like I think any addict you know, I think we have to have humility with our addictions and keep a close eye on them, so um, I think I'm always going to struggle with vulnerability and with letting people see my flaws. and recognize my flaws and my own Humanity to myself who said um I also realize that I am very fortunate and that um you know, I think who is given a lot as expected and that's why I'm sitting here having this discussion to having You know, I survived the ordeal of my You know, my past and what I went through in You know 2017 2018 2019 and 2020 um depended on me being very lucky, which means I had a lot of people around me and there have been some people who have commented that effect is, hey, you know most people don't have the resources that you have for the help that you received well, you know you went and spent, you know I spent five weeks collectively in a Residential Treatment Center for patients boarding schools, um, and that's not our thing. health insurance pays here in the United States.

I mean, I don't even remember how much it cost, but it was a lot, and I have access to these amazing therapists, so it's not lost on me that there are a lot of people who can't necessarily afford either in time away from work or in financial costs C what I've been very fortunate to be able to pay and while I can't apologize for those things, I'm not going to apologize for my good luck, which I will say. It's how I can pay it right, how I can take my fortune, my blessing and help other people with it and I think the best thing I can do is write a chapter like the last chapter of this book and be open about my story even though I don't know. feels good, it doesn't feel good to talk or write about these things the way it feels, you know it's easy and autonomous to talk about exercise and sleep, yes, thanks for sharing that you know perfectionism is a growing problem, In fact.

I was recently reading research from a psychologist in London about how perfectionism is growing around the world. There is a particularly dangerous form of perfectionism. Social perfectionism about what we think other people think of us, that if we just look at that, you know, what we think. think about this, it's based on a lot of assumptions that we may not know what they think and we are imagining what people think of us and the link between social perfectionism and suicide, so I would also describe myself as a recovering perfectionist um I often think about it in terms of you know, when there's a gap between our ideal self and who we really are, our real self in that gap, the bigger that gap is, the bigger the internal conflict, I think we experience that. , that's how I.

I've been thinking about it recently, but you're right, it's uncomfortable, you know, you know, you mentioned that you think you'll always have a hard time being vulnerable. I find it interesting and I also heard you say in previous conversations, Peter, that I know, since it's taken me 40-50 years to get to this point. I don't see this going fast. It's going to take me a long time to get there as someone who's maybe been on this journey since my dad died in 2013. I don't think so. necessarily it has to take as long as people think I don't really do it and I really feel like it depends on access of course I've done a kind of therapy called internal family systems Peter um by Dr.

Schwarz yeah. Which has been amazing, really amazing, going back to childhood situations, reframing them and then you know when you sleep with consolidation and reconsolidation in the brain, you almost establish a new memory of what happened. It's been really quite deep, so I kind of like somebody. who also described himself as a recovering perfectionist. I would like, as you know, to tell you as a fellow human being. I don't necessarily think it's something we always have to struggle with. I think we can. I passionately believe that we can. get to the root of these things and reconfigure them and change and I have certainly come to the belief that much of our personality is not who we are, it is simply who we become and if we apply ourselves to certain practices, we can actually change how we should Europe in the world um when I tell you that Peter or when I share my point of view with you um does it impact you? do you reject?

You think not? I'm a difficult case, it will take a long time. I mean what comes up for you when I share ideas like that, oh no, I completely agree and if I think about the progress I've made in three years, it's profound, I mean, I'm not the same human being. Three years ago there's no comparison and I actually think I talked about this on the podcast with Andrew Huberman or maybe it was Rich R, but it was one of those two where you know one of the hardest things for me. To get rid of that or one of the first things I had to chase was the inner monologue, which was a very, very destructive inner monologue and it was something that I had never stopped knowing, so there never was.

I don't have a conscious memory. of not having that harsh sometimes violent and horrible voice that spoke to me and not just silently like it would audibly. Also, if I made mistakes, you know, I berated myself for them and it didn't take a rocket scientist to know that a big part of the The problem was knowing what was at the root of it and then how I could do it. We fixed that because that was creating a lot of other problems and conflicts in my life, so without going into details, because I do on those other podcasts that we can talk about if you want, but the process of undoing that.

It was rooted in a very

daily

deliberate behavioral practice. It took me maybe six months to undo that voice, so that surprised me because I truly believed that it was a permanent feature of my existence that was as permanent as my height or the color of my eyes. and I was very surprised, I was delighted to know that the plasticity of the human mind could allow me to reconfigure that in just six months and now I admit that I worked very, very hard in those six months, but yeah, that was it. very nice, so no, I'm actually incredibly optimistic, you know, in 10 years I'll be, you know, in much better shape than I am now emotionally, maybe I won't be as physically and cognitively strong at 60 as I am.

I'm. 50 but I think emotionally I'll be in a better place and in other words I think the trajectory is positive thanks for sharing that going back to what we said earlier about the physical cognitive emotional conversation and of course we were discussing how you know , the physical and the cognitive get worse with age and I was more or less saying that yes, as you were demonstrating there, I think the emotional can improve with age actually and I don't know, maybe it can counteract someone with other things potentially , but that's a lot. uh, deeper and longer discussion without going back to the details that you already shared in those other podcasts.

I think what might be helpful in terms of a practical tool is just sharing what you had to do to change the negative voice in your head. Because clearly negative voices in our heads are so common, yours sounded particularly brutal. I have to say that when I listened to it, I also heard some elements of it in myself, but to see that dramatic change in six months I think is really empowering, would you mind? to briefly share what that exercise was that allowed you to do that, sure, so, the voice was basically, the voice of a guy, a very famous college basketball coach, former basketball coach in the US named Bobby Knight, so Bobby Knight was incredibly angry. manic, you know, Savant of a basketball coach, but he ultimately lost his career because of his temper and every game was like witnessing a crazy tantrum that he would have, so the exercise was framed as you know you have a board of directors that run your life, the board of directors in your head and unfortunately this guy, Bobby Knight, is the chairman of the board and we have to get him out of the boardroom, um, we have to get him far enough away from the boardroom so that you don't.

I don't hear him talk all the time, so the way we're going to do this is every time you hear him talk and that's going to happen every time you do something in the pursuit of what we would call performance-based esteem, so basically the most things. I am doing it in life, I am doing it to be able to generate myself, just as an alcoholic can turn to a drink or a gambler can turn to a slot machine. I turn to performance as the drug which is literally the drug I need. have self-esteem and every time those performance-based esteem activities fail to generate esteem because I fail at the activity, I turn the anger inward, just as an alcoholic would become enraged if he walked into a bar and ordered a vodka. and received water, he would get angry at the waiter, that's basically the cycle that's happening, so the exercise was every time you feel that happening.

I want you to imagine that he is your closest friend.who committed the act in which you failed, so, for example. If you're in your driving simulator and you know that driving is one of my big passions, then if I'm not on a race track, I'm in a simulator and you're having a bad day, you're just not driving well. you're spinning, you're crashing, your times are slow, whatever it is, normally you'd come out of the simulator and you'd be screaming and shouting and sometimes you'd even break the simulator. Instead, imagine that your closest friend was the one driving in the simulator. bad, what would you say?

You know to do this exercise you have to be able to picture the person, so for this exercise I would normally choose a friend of mine named Matt Walker, who you may recognize. Matt Walker wrote The Big Book of Sleep and Matt is a very, very dear friend who is also a total Motorhead. Gearhead uh loves cars every time he comes here the two of us will be in the simulator all the time so I would look at Matt. I would imagine Matt closing his eyes. and I would imagine what I would say to Matt if he drove that badly and of course I would be very kind, very loving, very understanding and I would record that conversation on my phone and I would send that recording to my therapist, so two or three several times.

Every day, my therapist would get one of these five-minute voice notes from me where I was talking to one of my friends in this type of situation and that was just the exercise that we had received earlier in this program. particularly when I spoke with Kristen Nef uh, who has done a lot of research on self-compassion. Yeah, you know, talk to yourself like you're talking to your best friend or a little kid, and I think we understand that intuitively, but I think what makes your exercise is the one that you were given to do so powerful that there's a additional component of responsibility is not just oh yeah, I wouldn't say that oh, come on, change the record in your heads no, you have to record that message and send it to someone Who's going to listen to it?

So maybe just talk about what was so powerful about sending it. Was it embarrassing? Will you read it? Will you think? Oh man, I have to send this to someone. The goal was to then play it back to them. to subliminally change the message you give yourself or just give us a little more detail if you can. I think I think the recording is important because I think when you say it out loud it's a lot more powerful than just thinking about it, it's one thing to say "okay," just you know, I shot wrong with my bow and arrow or I drove wrong in the simultaneous later, now I'm going to have good thoughts, but the reality is Bobby's voice.

It's too strong for me to outthink him in silence. I have to speak better than him. This is how the mind works through concentration and there are very few things that can harness your concentration more than the audible sound you make with your own mouth, so I have to speak more than this force in my otherwise mind. very strong and, by the way, sometimes he spoke well to me. Sometimes I would speak what he was saying, so I have to turn it up and then, secondly, record it and send it. It's not about being embarrassing, it's like you said, it's responsibility, there's a person who knows that two three four times a day I have some behavior that requires my perfectionism and it's a vehicle through which I generate self-esteem and therefore' I'm going to have comments, so it's actually those two things and so by forcing the audible overwriting of a historical way of doing things, I'm rewriting and by having the responsibility, I make sure that no matter how much I do it.

I do not want to do it. I do this by going back to what you said before Peter about having the means to pay for an impatient residential facility to deal with a lot of the internal conflict you were feeling at the time and wanting to pay for it. I'm just trying to think if there's anything in that exercise that people at home can use for themselves. For example, of course, it's not the same as having a therapist. I understand it, but it's as if, for example, you were recommending a patient work. Learn more about what that might mean for you.

I guess sometimes you can ask them to have an accountability partner who can check in with them to make sure they're doing it and they can help encourage each other. Could it be a version of this? be with a close friend someone you trust maybe your partner it could be you go actually you know what I'm going to ask them if for the next month I can do that exercise with them would you be willing to be that person? Yo, do you think that could be a good thing or do you see any potential problems with that?

I'd have to give it some thought, but my inclination from the start is probably not to select a romantic partner for that exercise. I think it would probably introduce some unnecessary tension into a relationship, but I think it could be done with a friend who may not be as ideal as a therapist because the advantage of doing it with a therapist is that, for me, I go once a week . talk to that person too and we're going to process those things and by the way some of them were so important that she would just call me right away like she heard it and you know, call me an hour later. just to see how I'm doing or something, so there's something to be said for that, but I think if the alternative is not doing it, yeah, then doing it with a friend, I think would be a much better option than not doing it.

Is there a practice you try to do

daily

or at least regularly that keeps your emotional health in tune or is it something you just do from time to time? No, no, it's a big deal and in fact, when I left PCS, which I write about in the book, it's the place I went to in Arizona in 2020. You know, I had a make-up contract that I did and the make-up contract I had red light behaviors, yellow light behaviors, green light behaviors, so red light behaviors were things. I never ever wanted it to happen again and if it did I understood it was a trip back to rehab.

The yellow light behaviors were warning signs. This was a very important part of the trip. One of the things that scared me the most in my life was. how seemingly unpredictable my crises had appeared, uh, again, I write about this in the book that I was so paranoid that it was like the space shuttle Challenger that, out of nowhere, exploded in the sky and that's the round. The space shuttle Challenger, which people don't remember, is the space shuttle that exploded in January 1986 and turned out to be a completely predictable disaster if people had been paying attention to what the engineers were telling them, so there were a lot of yellow colors. lights predicting that the space shuttle Challenger was going to explode that day, it's just that people didn't pay attention and now I had to identify what my yellow light behaviors were and they had to be stuck right in front of me on a contract. that I watched twice a day every day and every time those things that they did happened, they required an increase in therapy, an immediate discussion with someone, it was about cooling the flames and then there were the green light behaviors, which were the What are you asking? about what are the things that I have to do every day and these are the things that will expand my window of distress tolerance, that's the kind of figure that I include in the book, which is like I have to expand my operating range as much as possible.

As much as possible, this is sort of through the type of therapy that I call dialectical behavioral therapy and that's really geared toward making me as emotionally resilient as possible to stressors, so it's really through those. lenses that I board the day, but only to give. You are an example of some of the green light behaviors. Exercise is important, so exercise every day, but do it in an unforced way. This is a very important thing for someone like me. Exercise has always been important to me, but what I had to do wasn't. learn to exercise more, but sometimes learn to exercise less and learn that you know if on Sunday you're trying to do a double workout but ultimately it's the choice between spending a little more time with your kids or doing that second training in maybe the best thing to do is just spend time with the kids and not do a second training and be okay with that, yeah, and be okay with that being the key, that's right, yeah, yeah, and over time that becomes easier and easier. and easier, um, for a long period of time, about a year, I didn't allow myself to score in archery, I mean, in archery, when you do it competitively, you actually have scores, you keep scores of exactly where the arrows hit and for a time.

Last year I didn't do that, so I kept practicing archery but didn't score, in other words I had to eliminate part of the performance. Also, for six months I never drove the simulator and did archery on the same day. I know. These things sound a little crazy, but you have to understand it for someone who is recovering like me. I didn't want too many of these performance-based things to pile up. I also wanted to not look at my phone at that moment. I woke up around, you know, so let's say I woke up around 5:30 in the morning, the goal would be to not look at my phone or do any work until my kids left for school at 7:15, like this Just hanging out with my wife having coffee and playing with my kids, that was a very important part of the reset anyway, there were about I don't know 15 or 16 things in the recovery contract that were part of the behaviors of Greenlight and these things had to be done I'm always right, that was therapy that was checking in with friends once a week who I asked if they would support me, that was journaling, so there were a lot of things I had to do And it took me a while, you know?

This was a time-consuming process. Although you know that exercise is time-consuming, yes. I really appreciate you sharing it again. I think what you just said speaks to personalization. You had to figure out with your team, your assistants, your therapists what the right approach was for you. Another person you don't know. Scoring an archery shot has no relevance to them in their lives, but for you it was something you had to address and I think it's up to all of us to find what those things are for us. I found it really interesting when reading that chapter. in your book Peter, when you talked about the problems in 2017, um, I know you didn't write about these things in 2019, I heard you talk to Rich about it, um and then in 2020, so you had already been through this. trip, however, you said something that I highlighted and found really interesting at the beginning of March 2020, when things were starting everywhere.

I let my morning meditation practice go well. You let something important go. You know, dealing with a crisis. I understand. but it's one of those things I've learned in my own life, isn't it? There are certain things that I no longer call non-negotiables because I feel that the non-negotiable returns me to an old pattern of thinking. I agree, so I don't use that term anymore. I feel like there's a balance between discipline and compassion and I'm always trying to find the sweet spot between those two, but I really appreciate you sharing that and I think I think it's going to be helpful to people p i i I think you've written a wonderful book I No I'm sorry I've even scratched the surface of where I really want to go with this conversation, but just to end with Peter for the people who obviously want to learn. more can go in your book, but for the people who are doing well, I understand.

I understand your philosophy: it's about getting caught in early and not waiting until it's too late or too late before I start addressing things related to my health and longevity. I always like it. end the podcast with some kind of practical takeaways for my audience, so for that person who is feeling inspired and doing well, you've convinced me. I'm going to get over this now that I'm 40 years old. 'I'm not going to, what happened to my father or my brother or my grandfather or whatever, I want to take control of my life and my health, what would you say, well, if you are, yes.' If you are really committed, I would say get the data right, let's figure out what your baseline is based on all those metrics that matter and again, we present them all in the book correctly, so you need to know your V2 Max, you need to get a dexa scan and know what your almi is.

I mean again, if you really want to understand these things and yes, you're going to have to invest in doing these things. Whether it's the UK or the US, no health insurance company is going to pay for that, you're going to have to get it yourself and there are less expensive ways to do that, there are ways to estimate those things. Beyond measuring them by the gold standard, but what you want to do is take advantage of the fact that you're 40 years right and take advantage of the fact that, hopefully, you have four or five decades ahead of you to accumulate benefits.

This is a very different proposition than If you're in the last few years of your life, what I call the marginal decade, and you realize, oh, I want to do something about this, there's still value in making changes at any time, but you'll be able to move theneedle. even less so if you're talking about this through the lens of someone who is in middle age or even younger, what you want to do is say what changes can I make consistently. You know, I often say I'd rather have someone do seven out of 10 jobs. every day, then do 10 out of 10 jobs some days and zero out of 10 jobs other days, ping pong back and forth tends to produce inferior results as to what to do once you have those results.

I think results have to drive Okay, so if your V2 Max is in the 25th percentile, that's a huge opportunity, you have to do the type of training that will increase your V2 Max, increasing your aerobic efficiency, your fitness base. aerobic and your peak, yes by extension your V2 Max. you're already at the 80th percentile but your muscle mass and strength are at the 20th percentile, so that's where you just need to train disproportionately while knowing how to do things to maybe maintain your aerobic fitness. You know again that the list goes on and on if you sleep. is really what's suffering so that's where you need to focus and again we explain how to do it if you're overnourished and under-muscled then you're going to focus in strength training on reducing protein and calories and that's probably your biggest focus will be getting back to a level playing field of health, so I know it's not a very satisfactory answer because again it's an individual answer, but unfortunately I think at this level of medicine 3.0 um, it's the only way I can think of talking about these topics If you enjoyed that conversation.

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