Dr. Peter Attia - The Portfolio to Live Longer - [Invest Like the Best, EP.325]

27:12Yeah, there are some things where there are really specific risk factors that play into a given disease. And lots of people have done these types of analyses where the suggestion is that, look, even if you eliminated cancer, if you just said, look, imagine nobody will die of cancer. How much does that extend human lifespan? Someone's done that analysis and they claim the answer is like three or four years. I say, well, that's not that impressive. Okay, well, what about heart disease? If you could just eliminate heart disease and nobody could ever die of heart disease, what's the answer? And it's an equally kind of unimpressive answer.

27:50Those analyses are flawed in my opinion because what they ignore is exactly what you're talking about, which is the interrelationship of these diseases. And so in the book, I talk about these four horsemen of death. And they're loosely the diseases that kill us. But if you read the fine print, you'll realize that we're mostly just dying from three of the horsemen directly. But the fourth horseman is probably the one that has the biggest overall effect. Even though it doesn't show up on the death certificate as the cause of death, it's the gasoline that's being poured on the fire of the other three.

28:26So the three are cardiovascular and cerebrovascular disease at number one, leading cause of death, cancer, number two, and neurodegenerative disease, number three, at least at a non-smoking population, because I'm stripping out COPD, chronic obstructive pulmonary disease. But the fourth one is kind of a category I've created from a disease such as type 2 diabetes at one end of the spectrum, but also all the things that are leading up to that. So insulin resistance, hyperinsulinemia, non-alcoholic fatty liver disease, which progresses to non-alcoholic steatohepatitis, all the way to type 2 diabetes.

29:03Again, if you added up all the death certificates in the country and said, how many times does insulin resistance appear on it? The answer is never. No cause of death is insulin resistance. NAFLD is not a cause of death. You're not going to die from NAFLD, but if it progresses to NASH and cirrhosis, you'll die. Very few people are dying directly as a consequence of type 2 diabetes. It does show up on the death certificate. I should know those numbers, but they're not that big. But if you have type 2 diabetes, your risk of heart disease, cancer, and Alzheimer's disease is approximately 2x, that of someone who does not.

29:41So here's where you have to be able to say, I'm not just going to play whack-a-mole with these diseases. The answer is not just do infinite cancer screening and reduce your risk of cancer, or we're just going to treat lipid risk factors and eliminate cardiovascular disease. No, the answer is you have to do all of the above, including addressing metabolic health. And this is where the really unsexy, not terribly interesting word that I hate, lifestyle modification comes in. Because we don't really have amazing drugs to do that the way we have drugs to zap lipids or treat hypertension, which, by the way, can also be impacted by those metabolic factors.

30:20But this is why exercise, nutrition, sleep, stress management, again, they have the reputation for being so uninteresting because it's like, yeah, yeah, yeah, I know that, I know that, I know that. But it's like, no, A, do you understand how much power those things have? And B, do you understand how to dose them? This is the thing, right? I mean, every doctor knows exercise is important. We are not trained in what that looks like. We don't know what advice to give a person. And the same is true with nutrition. We don't really know what to tell people. We certainly don't know what to tell people how to sleep better beyond, if you're having trouble sleeping, here's a suite of medications that can help.

30:58There's a pill. Yeah. You said mindset earlier. When I was reading, I didn't think about it in those terms, but now it's very clear that that is central and incredibly important from doctors and researchers all the way down to the mass populace. I want to understand what could cause this mindset shift because strong body and this idea of exercise is just so incredibly powerful as we think about drugs that could affect our longevity. It seems like a lot of exercise of a certain type is probably the single best drug that exists, but it's not the easy pop the pill thing that medicine 2.0 mindset has, I guess, trained us as a species to think, oh, if there's a major problem, pop a pill and it gets better.

31:43So are you hopeful about this mindset shift? What can cause this? Because if that's the answer, which is, as you say, kind of unsexy as an answer, but still powerful, then we need to implement it. And it just seems like people are unwilling to work out as much or eat better or sleep better. These aren't the pills people want. It's a very good question, and I don't know the answer. So there are a few components that are embedded within that. The first is, is the transition to Medicine 3.0? Now, is it necessarily going to have to be driven by healthcare as the system, or can it be consumer-driven or patient-driven?

32:19So my hypothesis, which I'm happy to be wrong on, is that I actually don't think medicine has to lead the way. I think it can get dragged along the way. In other words, I think enough people can just say, I'm going to take charge of this. I'm going to be in charge of my own healthcare. I'm going to be in charge of my medicine 3.0 approach and my doctor will come along for the ride. There are five things that I talk about as the areas that we have agency over in terms of how we impact our health span and lifespan, nutrition, exercise, sleep, pharmacology, including supplements, drugs, et cetera, hormones, and all the tools around emotional health.

33:03And this book doesn't really go into much depth on one of those, which is the drug one. And part of the reason for that is that's the purview of Medicine 2.0. It would take too long to write a whole dissertation on that. And I wanted to focus on the four other buckets, which are the things that people don't need a doctor for. So if you think about it, if you assume that each of those is responsible for roughly one-fifth of the output, and it's not, clearly it's not. Exercise is actually disproportionately responsible for benefit. So conservatively, 80 % of what can impact the length and quality of your life, you don't need a doctor for.

33:40It's interesting that 20 % of that equation is all we learned in medical school and beyond. So when you encounter a doctor who has insight beyond eat less and exercise more, and there are lots of doctors that do have insights beyond that, You have to understand that those insights came to them through their own education and their own process of learning outside of what they learned in medical school or residency. Because there is nothing we learned in residency that taught us anything about how to provide instruction for patients. You know, I use a sort of glib example you may recall in the book, which is knowing that a patient with cancer needs chemotherapy is irrelevant.

34:23A person on the street knows that. You don't have to be a medical oncologist to help a woman with metastatic breast cancer by telling her she needs chemo. You need to know what her receptor status is, which chemo, what was the histology of her breast cancer besides even the receptors, how many lymph nodes were positive, how would you dose it, how would you stage it, how would you cycle it, all of these different things. That's where a medical oncologist comes in. Similarly, there's no insight in saying you need to exercise more or the CDC recommends that you do three hours of vigorous to moderate activity per week.

34:59Yes, so what? That's not specific enough. It's not helpful enough. People need, I think, more insight and I don't think they have to wait for their doctors. to give it to them. Look, that's part of why the book is written. It's part of why I have my podcast and stuff is I want to make sure that people can get the most powerful tools without having to wait for their doctors to provide them that insight. How do we know that when you consider those five things that exercise is so disproportionately impactful on the outcome? Well, I'll take one of them out because one of them I think can't be quantified.

35:35And I think for certain individuals may have a greater impact. And I might be one of those individuals, by the way, which is all the tools around mental health and emotional health. So that could almost be kind of a binary switch where without that one being in order, none of the other stuff matters. It becomes the problem of it doesn't matter how long you're going to live and how healthy you are physically. If your emotional life is in turmoil, who cares? So let's take that one off the table and then just say, if we talk about sleep, nutrition, exercise, pharmacology, we don't have and we will never have high enough quality randomized experiments to test head-to-head all of these interventions.

36:15So instead what we can do is we can look at deficiencies in each of these things and ask the question, what are the hazard ratios associated with those things? And we can also do that by combining other problems. And I'll just explain what a hazard ratio is because I've already used that terminology. A hazard ratio is the product of a statistical analysis that I won't get into in great detail because it's actually complicated calculus using something called a Cox proportional hazard, where you try to estimate what the risk is of a certain variable or behavior to an outcome. So for the purpose of this discussion, I'm going to talk about hazard ratios for all-cause mortality.

37:03That's the highest standard that we care about in medicine, which is, I'm not asking what the hazard ratio is for you getting cancer or even dying from cancer. I'm asking about the hazard ratio of you dying full stop, period, all causes, cancer, heart disease, you name it. So ACM, all-cause mortality hazard ratio, is the highest standard. The way a hazard ratio works is it's always reported as a number with a 95 % confidence interval. All of the numbers I'm about to spew out have a 95 % confidence interval that puts them in the statistically significant category, meaning we are at least 95 % confident that these numbers are not by chance.

37:41A hazard ratio of one means that this behavior has no effect on all-cause mortality. A hazard ratio of 1.1 means it is increasing risk by 10%. 1.15 would be 15%. 2.1 would be 110%. You're subtracting one from the number and that's your percent. A hazard ratio of 0.85 would be a 15 % reduction. A hazard ratio of 0.7, a 30 % reduction in risk, et cetera. Okay. So now we go about doing the analyses and we look at enormous populations and we apply statistical corrections and we say, lo and behold, what is known? Okay. So we talked about smoking earlier. We know smoking is bad, but how do you quantify how bad it is?

38:32Well, one way to do it is to take people who have smoked a certain period of time. Let's just say we say, let's take all the people who have smoked 20 pack years at least. So they've smoked say a pack a day for 20 years or two packs a day for 10 years. and let's compare them to people who are identical as best we can make them statistically, except that they weren't smokers. No. Is that perfect? Absolutely not. Here's why. Anybody who's a smoker versus a non-smoker, there have to be other differences between those people that we can't correct for because a smoker by definition is not going to be as health conscious.

39:05So even though we think we're correcting for what they eat, we know we're not fully connecting for what they eat, exercise, et cetera. So all of these numbers, you have to take, it's almost amazing that we put decimal places on them. We should almost round them. Just round them. Yeah, yeah, yeah. I think we're putting false precision on them. But nevertheless, the hazard ratio for smoking and all-cause mortality is about 1.41. Call it 1.4, meaning directionally at any point in time, a smoker compared to a non-smoker has a 40 % chance greater death rate in the coming year. Again, not surprising.

39:41I mean, it is amazing, and it is amazing that people still smoke, sadly. But yes, because of course smoking impacts every chronic disease, right? It's enormously increasing your risk of cardiovascular disease, cerebrovascular disease, Alzheimer's disease, and of course cancer. Okay, let's look at type 2 diabetes. Type 2 diabetes, again, depends on the study. Directionally speaking, it's about 1.3 to 1.4 is the hazard ratio. So roughly a 30 to 40 % increase in all-cause mortality. If you look at hypertension, having high blood pressure, it's about 1.2. So about a 20 % increase in all-cause mortality.

40:20Probably the greatest example of these would be something like end-stage renal disease. So this is a patient whose kidneys don't work anymore. They're now on dialysis. And that comes with a lot of other medical baggage. Of course, that bakes in a lot of other diseases. A lot of times those patients already have devastating hypertension, type 2 diabetes, et cetera, as the precursor to that. Not always, but often. And that comes with a hazard ratio of about 2.75. That's 175 % increase in all-cause mortality. So let's think about those for a moment. That captures a lot of the nutritional stuff. Like if you put obesity in there, it's going to be maybe 1.1, about a 10 % increase.

41:01And that's lower than type 2 diabetes because, of course, obesity per se actually isn't highly associated with mortality if you normalize for metabolic health. So obesity is just a very crude, easy-to-measure proxy for bad metabolic health, but technically only about 70 % of people who are obese are metabolically unhealthy, about a third are not. Similarly, about 20 % of lean people are metabolically unhealthy, and their risk is much higher. So the real issue is metabolic health, but nevertheless, just to give you a sense of it, obesity and type 2 diabetes, you're seeing we're talking about somewhere between 1.1 and 1.3.

41:43So there you're basically seeing the impact of nutrition. Similar exercises with sleep. People who are sleeping less than sleeping more, yes, there's unquestionably a higher association with mortality, but it's really on the order of 1.1, 1.2, 1.3, 1.4. Not to diminish those things, but when you start to compare those results to the exercise results, and again, don't look at it through the lens of people who exercise versus people who don't. You look at it at the end stage. That's why looking at type 2 diabetes is the integrator of the behavior. So what's the integrator of exercise? Well, the two best ones, three best ones, are VO2 max, muscle mass, and strength.

42:26Because you can't have a high VO2 max without doing a lot of hard exercise. You can't be in the top decile or quartile for muscle mass and strength without doing some work. It doesn't have to be necessarily exercise, by the way. You can just have a very physically demanding job. But The point is, there's no way to hide behind it when you look at these integral functions. And here, the hazard ratios, Patrick, are staggering. When you compare top decile to bottom decile for strength, we're talking about hazard ratios of three, 200 % difference. The biggest gap is when you compare the bottom 25 % for VO2 max.

43:08Have you ever taken a VO2 max test? I haven't taken one. I know the concept, but I haven't taken a test. It's a test where you'd either be placed on a treadmill or on a bike. You'd have a mask strapped over your nose and mouth that would be incredibly precisely measuring your oxygen consumption because we know that the air you're breathing in is 21 % oxygen. So it's just got an O2 sensor and it's measuring how much oxygen is coming out. So if it's coming out at 17%, it knows 4 % was consumed. That is converted into a flow rate. As you're doing this test, it's measuring how much oxygen you're consuming in liters per minute.

43:43Now, you and I are sitting here having a discussion right now. Our oxygen consumption rate is incredibly low. It's about 300 milliliters per minute. That's low. When you're exercising, the more demand your muscles place on the generation of ATP, the more oxygen you consume, and that number goes up and up and up and up. And by pushing you and forcing you to exercise until the point of failure, we will at some point achieve a maximum level of oxygen utilization. And that's called your VO2 max. And that number is more predictive of how long you live than any other number we have. So if you take people who are your age, your sex, and you compare the bottom 25 % to the top two and a half percent, the hazard ratio is a little over five.

44:30That's a 400 % difference in all-cause mortality. Now, some people are going to say, well, come on, Peter, who could be in the top 2.5 %? And the short answer is actually anybody could. It's just a question of how much time you want to train and how long you want to be training. It's a consistency game. You don't have to train 20 hours a week. You can train a fraction of that, but you just never get out of shape. You just constantly work towards improving that. But if you take even something more modest, which say, what if you just take the bottom 25 % and compare them, so call that the first quartile, compared to the third quartile, so people between the 50th and the 75th percentile.

45:04Now that's not a stretch. There's no human being that is not capable of being in the third quartile for their VO2 max. So when you compare bottom quartile, which is basically people who are never doing any exercise, to third quartile, which could be achieved doing five to six hours of exercise a week, you're talking about a hazard ratio of 2.75, 175 % difference in all-cause mortality. So it's going through these types of analyses, Patrick, that makes it unequivocally clear that exercise is indeed the greatest driver, the greatest lever we have at a longer life, but it comes with a caveat, which is it has to be the right kind of exercise.

45:49These generic recommendations of just move, just be active, just garden a little bit. No, that's not going to cut it. I mean, those things matter, but you won't get the benefits I'm talking about without doing much more specific training geared towards strength and cardiorespiratory fitness. I love the Nassim Talib idea of don't tell me what you think, just tell me what's in your portfolio. I'd love to understand your portfolio of exercise. That's one of the things that really stood out to me reading the book was the exercise that I'm probably personally most inclined towards, which would be like a six mile trail run or something, not like all out, just probably like a zone three, zone four kind of thing.

46:28It's fine. I get a lot of joy out of it, but it's maybe not the ideal thing to form a great portfolio of exercise. So what has become your portfolio of exercise? Because I think you've got all the data. So you tell me what's in your portfolio. Three comments. First of all, I wasn't aware of that statement by Nassim. That's a great statement. Put your money where your mouth is. I don't really care about the pontificating. Just tell me what you're doing. Two, I would disagree with you. And I think that that's a great piece to have in your portfolio. I think that's super important for two reasons.

46:56One, it's actually great exercise. That should clearly form a basis of your aerobic training. Secondly, there really is no better way to integrate physical health and emotional health than outdoor exercise. So Michael Easter, who's a good friend of mine and wrote an amazing book called The Comfort Crisis. I'm not sure if you've read that. Oh, no, I haven't heard of it. You should read the book, and you should interview Michael. He talks a lot about the benefits of being outdoors from the standpoint of just our natural evolution. He argues in this book, I've gone back and looked at some of this literature.

47:29We'll never know the answer to this because you can't do the experiments. But teleologically, the following makes sense. Did we evolve around symmetry? No chance. We never saw symmetry for a billion years, right? Meaning going back to when we were worms and flies and things like that, we never saw symmetry. Nature is fractal. It is completely asymmetric. It's at least plausible that our hyper-symmetric, perfectly manicured indoor worlds are at least, if consumed in excess, not necessarily great for our psyche. There is something regenerative about being outdoors. There is something regenerative about being in nature.

48:15Even if, again, we can't know that for certain. There are studies that have looked at that by doing functional MRIs, and they all seem to suggest that, but I can also poke holes in those studies. But I think I can't deny the experience that I have when I go outside. And if I'm at the end of a long day, I open my day by exercising and I close my day before dinner by another type of exercise. I'll answer your question in a moment. But rucking has become kind of an obsession of mine where basically I just put on like a 60 pound backpack and I go for a walk before dinner. And A, it's physically strenuous, right?

48:4960 pounds walking around up and down the hills of Austin is pretty strenuous, but I don't take anything with me. This is a very important part of it. There is no phone. I'm not listening to podcasts, audio books, or music, and it's just it. All I can hear is the breeze blowing and the wind moving the leaves and things like that. And that's a very important 45 minutes to an hour for me. And then I come home, have dinner and get on with the day. Okay. So to answer your question, you're getting that through trail running. You're being out there, you're getting the workout. It's a much better workout than say, if you were running through the city.

49:20Okay. So my portfolio is purely focused on being the best version of myself physically in the last decade of my life. So everything is geared towards solving that problem, which the model I use for that is called the centenarian decathlon. What are the most important physical events or things, activities of daily living and sports and activities that I want to be able to do in the last decade of my life? So call it 80 to 90. Let's assume, hopefully I can lift to 90. So what am I going to be doing between 80 and 90? And then everything has been reverse engineered from what those activities are to what physical skills I need to have.

50:01So how strong do I need to be? How much aerobic efficiency do I need to be? How high a VO2 max do I need to have? How much balance do I need to have? How much foot reactivity do I need to have? All of these things. And so what I'm doing is about four hours a week of steady state zone two cardio, about 30 minutes a week, up to 60 minutes a week of higher intensity cardio, so pushing that VO2 max system, about six hours a week of strength training that's split mostly equally between upper and lower body. And within that, there's lots of details. What am I doing? And then rucking probably three to four hours a week of rucking.

50:42When you say it that way, it sounds like a lot, but I want to talk about the mental side of the physical working out because I think a lot of people think of this as a nasty tasting medicine. They wish there was some spoonful of sugar that helped the medicine go down. But my experience with exercise is that in the period between when you start, when you don't want to do it to when it's habitual, there's this kind of like valley of death where it sucks. On the other side of that valley, it's actually all sugar. Like it becomes the best part of your day, not an obligation. And I'd love to understand why that is.

51:14I'm not sure if you experience it the same way, but for me, when I'm in shape, there is nothing that I am more excited for than like a long, hard trail run. Whereas right now I'm not particularly good shape. And the thought of getting going again is like, ah, damn it. You know, it's going to burn and hurt. My lungs are going to hurt. Everything's going to hurt. But it seems like that's like a misunderstanding that it's like a medicine when in fact, it might actually be like the greatest experience once you get into the habit of it. Are there underlying biology reasons for that experience of almost euphoria associated with exercise?

51:46Certainly much has been said and written about endorphins, which are literally chemicals that are produced by muscles. There are many chemicals, by the way, that are produced by muscles. They're called myokines. So yes, there are absolutely neurochemical signals that do make us feel better when we exercise. I try to understand this through the lens of other people. So for whatever reason, exercise has always been something I've loved. So it's harder for me to relate to the people. I know these people, right? I have patients who say, Peter, I hear what you're saying. I know this is important, but I just don't like it.

52:19And I'll do it because the data are so compelling. There's no joy in doing this, or I need to find other ways to make this enjoyable, which means I have to do it with somebody else. I can't do it without a trainer being there, or I can't do this without having a movie on while I sit on that bike and suffer. And I guess I would say that's okay. It's better than the alternative. And certainly, if you can find ways to bring other things into it, such as being social while you do it, I think that's great. I also think that you're right in that once you get over a certain threshold, the consistency is there.

52:54I think there's no feeling like it. And there are many days even now when I don't really want to exercise. Usually for me, it's more of a temporal issue. So if I don't get my workout done first thing in the morning when I normally do, I just develop apprehension about the day and my desire to go in even an hour later is lower. Now, I'll always make myself do it, but it might take half an hour before I'm relaxed and enjoying the workout. So I can at least relate to that component of it, which is, I just have this apprehension. I should be doing something else. The emails are piling up and whatever else is sort of getting in the way.

53:30But yes, maybe there's an analogy here to investing. If you're talking to kind of a 30-year-old who's finally starting to pull in a big enough paycheck that they don't have to live paycheck to paycheck, there is a discipline that comes from saving. And it's not easy. But if you get into the habit of doing it automatically and it's no longer a decision, I'm signing up for a 401k plan and that money is coming out of my paycheck before I see it, it hurts a bit less than if you have to make a decision about it every single time. you get a paycheck or you get your full paycheck and then you have to go in and make some decision to go and invest it or something like that.

54:10And I think with exercise, if we just automatically decide we're going to do this thing, it's going to be done early in the day. I am an advocate of doing it early. I do find that compliance is much easier if it's done before you start work than after work. And I also think it sets your brain up better for the day. So part of that is just developing a habit around doing something. And then before you know it, it actually becomes pretty automatic. It's hard to go there, especially when you frame things in terms of hazard ratios. And I just know we're about to collapse. That isn't a lot. But I asked the question because of our first conversation where we talked a lot about caloric restriction, dietary restriction, time-restricted feeding, and just this kind of general concept of nutrition where intuitively it seems like if I eat nuts and salads and good lean protein, I'm going to feel better than if I eat chicken fingers for every meal.

55:01Not much more to be said about it than that. But it seems like your personal views and the data have evolved quite a bit from, say, six years ago when you and I first met and talked about this. Can you say how they've evolved and the degree of importance that you place on nutrition, let's say, with your patients or for yourself relative to six years ago? I think nutrition is obviously important. And when it's really out of balance, it's... You wreak havoc. Yeah, absolutely. Just as the same is true with sleep. So if a person is sleeping four or five hours a night, either through choice or through pathology, that has got to be fixed.

55:39You're not going to make tremendous inroads on anything else if their sleep is that bad. But once you get to the point where you're sleeping seven to nine hours per night, which is basically the, oh, I don't know, that's probably the 2.5 to 97.5 arc of the distribution. Once you're in that zone and your staging is reasonable and you're feeling well-rested when you wake up, that's it. You don't really need to worry about this problem anymore. One of the things I get a little bit concerned about with the proliferation of sleep trackers is we get a lot of people who are sleeping just fine. They're getting seven and a half hours of sleep a night.

56:20They feel fine, but their sleep tracker is telling them there's a problem. And it's creating so much angst that doesn't need to be there. I had to stop them for this reason. Yes, exactly. And I do. I force patients to take tracker holidays. And I sometimes do myself if I just get a little annoyed. So the point is that sleep is an area where you can really get punished if you're outside of optimal. but once you're optimal, there's no super optimal. I think the data would really suggest the same is true for nutrition. If you're really undernourished or overnourished, those things should be corrected.

57:00Probably the overnourished is a bigger problem. I mean, it clearly is from a numbers perspective. It might also be health-wise a bigger problem, at least in the developed world. Once you're in that zone of being adequately nourished, it's far more important to be focusing on metabolic health and lean mass than to be thinking about the subtle nuances of, well, how much fruit should you eat? The reality of it is, I don't think that those things aren't important. I want to be clear. There's many topics I did not write about in this book for the sake of space and time. And certainly one of the things I'm very interested in is the relationship that soil has on food.

57:41This is a rabbit hole I've gone pretty deep down. And I think there's very little doubt that food grown today doesn't have nearly, maybe even half the nutritional value that it could have or should have if the soil it grew in were healthier. So there's no doubt that we could be eating better food. But I also think most people tend to over-index that at the expense of exercise. If you look at the absolute battles that people have over social media with respect to this diet versus that diet, and what about being vegan, what about being paleo, and it's like, it might not actually matter as much as you guys think.

58:22Are you in energy balance? Are you metabolically healthy? Are you getting enough protein? After that, I almost joke that I didn't want to write the two chapters on nutrition because it creates so much substrate for people to argue about things. And what I really want to say is like, those are the three questions that matter most. And the rest is just tactics or in strategy around what to do. And of course I go into all those things. How do you use dietary restriction, time restriction, caloric restriction to address the crisis of overabundance, which we have. So most people are overnourished and I don't think there's some magic around how you fix that.

58:58The operationalizing of it is hard, but the strategy is really simple. You can calorie restrict, dietary restrict, or time restrict. Each one has advantages. Each one has disadvantages. They're not mutually exclusive, but they are collectively exhaustive. Try the one that works for you. If you fail, go try another one. What I'm trying to get away from is kind of the dogmatic view that there is a right way. Is there a VO2 max equivalent benchmark for metabolic health? I'm just trying to understand what metabolic health actually means. There isn't a single number the way there is for peak aerobic performance, but there are several things that do matter.

59:35So one of them is actually also a functional test. So if you look at a person's zone two capacity, so zone two is, this is a very technical definition, but basically the highest amount of work you can do. So wattage on a bike, for example, while keeping lactate below two millimole. And lactate below two millimole seems to be empirically the place at which you can maintain a steady state, where lactate doesn't net begin to accumulate. So at a lactate of two, it seems that you are able to maximally produce and clear simultaneously so that the level doesn't get above two. A more practical way to assess that is about the highest level of work you can do while still carrying out a conversation, albeit difficult.

1:00:23So if you can't carry out a conversation, you're out of zone two, you're into zone three. If you can speak, but it's easy, you're in zone one. So zone two, especially the upper end of zone two is, I did a zone two workout today. If my wife, and I'm doing it on a stationary bike, if my wife comes in and starts talking to me, I can talk to her. I just don't really want to. If my brother calls me, I'll pick up the phone and we'll talk, but I'll also say, hey, can I call you later? But I can certainly carry on a conversation. So that's what we call the RPE way about determining it, the rate of perceived exertion.

1:00:59But the more technical ways to do it would be doing it based off lactate levels. You can estimate it based on your heart rate. But truthfully, I think that perceived exertion is the best way to do it for the average person who doesn't want to be checking lactate levels. Well, the more work, the more wattage you can generate at that level, the more metabolically healthy you are. If you look at someone with type 2 diabetes, they can barely put out one watt per kilogram of body weight before they exceed that threshold. If you look at the best cyclists or runners in the world, they could put out four watts per kilo before they exceed that threshold.

1:01:36A master's athlete might be two and a half to three watts per kilo. So where you are on there is huge. Then we look at other things like glucose disposal. So using something like an oral glucose tolerance test, what happens when you're challenged with 75 grams of glucose? How much insulin do you require to put it into your muscle and how high does your glucose get before you put it away? Looking at other markers like triglycerides, which are another marker of fat storage in the liver. Looking at transaminases, inflammatory markers, All of these things kind of factor into it. But no, there is not one single number that is the integral of it the way that we have for peak aerobic performance.

1:02:15What do you hope happens to the industry of health and healthcare in the coming decade or two, given everything we've talked about today and this hopeful transition to medicine 3.0 to address slow death? You mentioned earlier being more patient-led and dragging the healthcare system along could be a feature, not a bug. But holistically, what do you think the healthiest thing that could happen to the industry itself is? The challenge with the healthcare industry is that it has three issues that are equally important and intimately linked. And every time you try to solve one, even if you make improvements in it, you tend to make the others worse.

1:03:00So those three issues are quality of care, access of care, and cost of care. And if you take stock of where the United States is, we're pretty good on quality of care. In fact, despite all of the things we'll say negatively about the U.S. healthcare system, if you can afford and gain access to the best care for medicine 2.0 problems, the U.S. system is very good. Now, it doesn't have great care on the medicine 3.0 side as we've discussed, but it's pretty good on the medicine 2.0 side. But access is pretty bad. Medical costs are the leading cause of personal bankruptcy. And our per capita spend on healthcare is unbelievable.

1:03:47I think we're up to about, God, it's got to be like$14 ,000 or$15 ,000 per capita at this point. I mean, it's absurd. Yeah, crazy percent of GDP. Yeah, it's about 18 % of GDP. It's out of control. It'll bankrupt us before anything else does. I'm convinced we will have to address this problem before any other problem for solvency. And then the third one is access to care. So you have both the cost issue, which we just addressed, and then you have how many, what fraction of people are uninsured or underinsured and suffering these problems. So I don't have a solution for that problem. I mean, I wish I could sit here and say, oh, and the solution is we just have to do this because you don't.

1:04:23There are like 10 things that have to be done to address that, then I think a lot about that problem. That's not what I'm really writing about. I think what I'm really writing about is at the individual level, independent of those problems being fixed, what can you do? Because I certainly, for my health and the health of my patients, don't want to wait for the system to get better. I don't want to have to wait for medicine as a system to switch to 3.0 or wait for costs to come down or wait for access to be expanded to everybody, because I do believe that healthcare should be accessible to everyone.

1:04:57I do believe healthcare is a right and not a privilege. And I think that we do require some single payer involvement. I don't think a sole single payer system will not solve our problems. It will solve one problem. It will solve access, might even solve cost, then it will erode quality. Just look at what's happening in Canada and the UK. It's going to have to be a super complicated solution, of which I have lots of thoughts, but again, not thoughts I wrote about because I just felt it was more impactful to write about it at the level of the individual and what they need to do for themselves. Thinking back to my little mantra, incredible amount of insight around this notion of strong body, both through exercise and nutrition and sleep.

1:05:39And some of those numbers are just staggering. And I think even just for me, I consider myself a very active, healthy person. It's so much motivation to really emphasize exercise and a strong body. What about calm mind have you learned through your own experience, through research and the data, through working with patients? When I say calm mind, what does that bring to mind in terms of both importance as an end and also the means to achieve that end? Well, I mean, I think there's definitely a couple of ways to think about that. So anybody who's ever played around with mindfulness-based meditation, which I have quite a bit is sobered to realize how noisy the mind is.

1:06:22That type of meditation for folks who haven't done it is a meditation where you focus on an object, usually the breath. It's an easy one to focus on. And the whole goal of the meditation is just to be as aware of the breath as possible and to notice every time your mind wanders off the breath onto a thought. and the exercise is making that realization and bringing the mind back to the breath. So contrary to maybe what people might think who haven't done this meditation, the goal is not to stop thought because that's not actually possible. It's not possible for more than, in my case, a few seconds.

1:07:01The goal of that exercise, Dan Harris, I think, says this so well. He's like, the muscle, the bicep curl of meditation is the exercise of noticing that the mind wanders and bringing it back to the breath or the object of meditation. And if that happens a hundred times in a 10 minute meditation session, that's not a failure. That's not that you failed a hundred times, that you got a hundred reps in. Nice way of thinking about it. Yeah. I think that's one of the most compelling arguments I ever heard for meditation. the very first time I heard Dan say that. So what does a calm mind mean? Well, it doesn't mean a mind of no thoughts.

1:07:39Maybe there's some Buddhist monk in Tibet for whom that's the case. For me, it means an awareness of when my mind is hijacking my behaviors. That happens a lot. For me, that's been learning to develop an emotional awareness. So that means recognizing visceral sensations. So for example yesterday My wife got upset at me for something and It was actually being able to stop and notice the physical feeling in my stomach As I was getting angry so she was getting upset at me and I felt like she was kind of Harping on a point that she'd made 10 times and I sort of felt like Okay, you're right, but you don't need to harp on me for the 10th time and so the difference is five years ago, I would have barked right back and I would have escalated.

1:08:35And yesterday, instead, I was able to pause, notice the sensation, understand that I was getting irritated and simply not react and just say, you know what, how about I apologize again? Yes, I've apologized nine times and I probably don't need to apologize a 10th time. Like in other words, it's not my obligation to do so, but harmony matters more to me than being right. And in the end, she is right. Everything she's saying is right. I'm just annoyed by the fact that she's needing to tell me for the 10th time that she's right. So I just said, okay, yeah, you know what, honey, you're right. I'm really sorry.

1:09:11That was dumb of me to do. And I should have been more clear about X, Y, and Z. To me, that's calm mind. It's almost slow mind maybe for me is how I think about it. When I think about calm mind, it very closely relates to the last one, which is house full of love. And another way of saying that is the value of relationship, maybe the house of your wife and kids being the most important, but not ending there. And that in my experience as someone that really does is not imbued with a calm mind, but rather with a fairly like hyper sensitive, hyper vigilant mind that by calming it in some weird way it makes room for more love in the house in an interesting way.

1:09:52And I'd love to hear what you've learned about the importance of household of love relationship, where that slots into this big discussion about what it means to live, not just a healthy and a long life, but a good life. And it seems like this final category is the arbiter of that. We don't have a VO2 max for that, or maybe we do, but I've seen you talk about eulogy versus resume virtues before. What an incredible, powerful little term. And I'd love to hear your thoughts on The House Full of Love and its importance. Yeah. And of course, I'm taking that from David Brooks, who wrote a great book called The Road to Character, which is one of the books that I stumbled across in the airport during the depths of my despair.

1:10:40And I got very lucky. This was March of 2018. I was really at kind of a rock bottom. I got invited to give a talk overseas and the talk happened to be on my birthday. And normally it would be like, well, I can't go because it's my birthday. Like I'm not going to go and miss my birthday with my family. But at the time things were so bad at home that it was like a no brainer. It's like, of course I'm going to go because it's better than the alternative, which is sitting here alone and not being able to celebrate my birthday with anybody. So I went and in the airport, I happened to pick up David Brooks's book.

1:11:15I don't know why. I don't know what drew me to it, but sure enough, I just grabbed this book, The Road to Character. And the book talks about the differences between eulogy virtues and resume virtues. And it was just the right thing for me to read at that moment in time. And I realized, boy, and it's an obvious realization, but I don't think I thought about it through this way was everything I've done to date, and at the time, how old was I? 45, I guess. Every single thing I've done to date has been resume boosting. Nothing has been eulogy boosting. My eulogy is going to be very hollow. It'll just be the usual platitudes that people say.

1:11:53My kids, if they were old enough for my wife, would really have much to say about me that is exceptional. They could talk about how smart I was and how hard I worked and all of these things, but I know deep down that that's irrelevant. That was a real turning point. Now, like most turning points, at least turning points of substance, that doesn't immediately result in a change. It's a very slow process, but that's part of the stonemason hitting the stone. And yes, eventually that stone is going to break and it will break, of course, as the Jacob Rees quote is, not from that hit, but all the ones that came before it.

1:12:33And that was a very big hit that didn't result in the stone breaking, but was clearly a part of the stone finally breaking a couple years later. As you think about the evolution of purpose in your life, and it's something I'm just always thinking about and curious about for other people, can you describe the role of purpose in life and the degree to which you feel like you are operating from a virtuous purpose or clearly defined one? We think about this with companies all the time. Most people just don't know what they're doing or why they're doing it. They're just doing stuff. And very often purpose is borrowed.

1:13:09This is like the mimetic idea. Everyone else seems to want this, so I guess I should, so I'll do the stuff to get that thing. How has your own feeling of purpose or definition of purpose evolved over time? And anything you would share with others that might be considering that same question? Yeah, and it's an area where I just feel like I have such little knowledge beyond myself, I hesitate to extrapolate. So I can only say that for myself, sense of purpose is something that is becoming narrower and narrower. And for me, that's a good thing. So for some people, they need a bigger and bigger sense of purpose.

1:13:47I think for me, I have always, from the youngest age, due, I think, to so much of the insecurity and inferiority that I felt, believed I needed to have the greatest sense of purpose. And I needed to have the greatest impact. And I needed to be doing something spectacular. With each passing day, I will tell you that my sense of purpose and my focus is becoming narrower and narrower. And I don't care about much outside of my family and my friends in terms of my sense of purpose. My sense of purpose as a father is far greater than any sense of purpose that I have as a doctor, as an author, as a podcaster, as an investor.

1:14:36All of the other hats that I wear that do give me purpose and do give me joy and do challenge me and all those things, they don't compare to the thing that matters to me most, which is, are my kids going to be well-adjusted humans? Are my kids going to have the skills to avoid the pitfalls that I fell into? And what am I doing about that? And also, there's an urgency about this that I don't feel with anything else, which is we have such a small window of time to be with our kids. I heard on a podcast the other day, and I've seen these data elsewhere, so I think this is - This is the Tim Irvin thing, how you spent all your time with your kids by the time they're 18?

1:15:17That's right. By the time they're 18, you're pretty much done. And in my case, it was even less. Once I went to college, I never lived under my parents' roof for another day because even in college, I stayed in the town and got jobs in the math department or things like that. And then boom, went off to medical school in another country. And then I was never back. Been back to Canada a handful of times. So when I think about it through that lens, I'm like, God, nothing else matters. This is the only thing that matters. I'm sure there are some people who could use a little bit more sense of purpose and also need more purpose and fulfillment from their work outside of their family.

1:15:53But for me, I think it's been more about shifting it back to what I truly think matters more. It's amazing to me hearing you talk at the beginning and now at the end of our conversation about the motivation for large effort and purpose being building evidence to disprove an insecurity. Like it's such an unhealthy, I think so many successful people, my friend Graham Duncan has this idea of the insecure overachiever and the incredible things that they tend to do. They tend to be able to move mountains and the effort and the accomplishment looks so impressive from the outside, but the intrinsic motivation, maybe it's unhealthy.

1:16:30And that you saying having a narrower and narrower purpose, it feels like permission almost to embrace a healthier form of motivation. I find that to be a very lovely idea. If we think about closing down our conversation and everything you've learned in the book, and I forced you to condense it down to an index card that maybe I'll do this. I'll pay to have it sent everywhere or plane fly overhead and drop them over New York city or something. What would you put on the index card? What's the font size? Up to you. Legible. No, it's funny. I was interviewed the other day. I forget it was an outlet.

1:17:11It was kind of a media outlet. And they asked me a question that I've been asked so many times. And it's typically you're asked on these morning shows and stuff. The question was like, what is the secret to longevity? What's the one thing? The first 10 times I was asked that question, I came up with some sort of nuanced answer. And then the final time I was asked yesterday, I just said, you know what? Honestly, if it could be distilled into one thing, I wouldn't have written a 489 page book. It's not amenable to that. So I won't attempt to do that. I won't attempt to synthesize the book into a three by five index card.

1:17:44I don't know the answer, Patrick. That's a very hard question because it's going to really depend on who's reading it. My mom used to wear this shirt that said, eat right, exercise, die anyway.

1:18:00shitty question well i think it's like look maybe you have several versions of those cards and given that this is just a magical thought experiment when you sprinkle them out of the airplane over new york city we imagine that each card lands in the hand of the right person if there's a person who's just not exercising much that card is just going to talk about you can literally add 10 years to your life if you adopt this. And oh, by the way, you're going to feel and perform and function so much better, especially at the end of your life when most people are in so much pain. If it's the person who, we didn't talk about this kind of stuff, but if it's the person who has an elevated LP little a and doesn't know about it, maybe the card simply says, go and get your LP little a checked.

1:18:46And getting this addressed is going to save 15 years off your life when you don't have that premature heart attack that you don't know is coming because you don't know what LP little a is. And by the way, if it's the person who's outwardly successful or not outwardly successful, but who's entirely miserable and their relationships are all in hell, sort of the person I was, then the card is going to say something about, you got to stop everything you're doing and get help here. And you have to be willing to address the demons that got you in this position and nothing else is going to matter until you fix this.

1:19:16And it's all a shell game. you're just numbing your pain with achievement or wealth or whatever else you're pursuing until you get this addressed. So we could probably come up with a dozen of those index cards and just, I don't know, hope that math gets them in the right place. On the back of my shitty morning show question, you've done a ton of interviewing of your own now. What have you learned about doing that well? As with many things I've seen you do, It seems as though the rate of improvement has been pretty good to start. But recently, I think they're just incredibly dense and interesting and clearly on the thread of your own curiosity.

1:19:55You're not filling in a chart of topics. You're pulling a thread of your own curiosity with the world's best people on those topics. And the topics, obviously, they center around health, but they range widely from there too. What have you learned about the experience of interviewing so many talented people and doing that well? something I'm always trying to get better at. Yeah. So am I, Patrick. It's hard. It's really hard. And there's a part of me that wishes it was all I did. So when I meet people for whom podcasting is their job, I'm quite envious because I think, God, if I had 20 more hours in my week or 30 more hours in my week to put into this, how much better could I get?

1:20:34For example, one thing I don't do, I never go back and listen to my podcasts. So a lot of times in an interview, I'll screw something up, say something, and I'll realize that wasn't the right question. But that's nothing compared to what I know I would get if I went back and listened to it as an observer on the outside. So that's an enormous shortcoming. There aren't enough hours in the day because I've opted for something that I think is even more valuable, which is I listen to other podcasts. And I'm listening for podcasts where there's a confluence of two things, my interest in the topic and the quality of the interviewer.

1:21:12There's six or seven podcasters, you being one of them, Patrick, who I really love listening to both the content. The content is interesting to me, but also they're very good interviewers. And I learn. Barry Weiss is one of them. Sam Harris is one of them. I could rattle off who all these people are. And I'm a student of this stuff and I just want to get better. And I think I started out at a one out of 10. I would hate to go back can listen to my first year's podcasts. I'm probably a six out of 10 today and we'll never get to be 10, but if we can asymptote at nine, that would be awesome in a couple of years.

1:21:45One of the coolest things about you is you change your mind with the data. You change your mind with experience and through investigation. What is the frontier of your curiosity today? I think clinically, a lot of it has to do with how can we organize all of the information we have on patients in a risk-based dashboard that allows them to see what we see. So behind the matrix, we internally have such a convoluted, complicated way of organizing risk factors. We see about 40 or 50 inputs into our risk matrix around these seven variables of cardiovascular disease, cancer, neurodegenerative disease, cognitive decline, physical decline, emotional decline, et cetera, orthopedic injury.

1:22:39But we're still struggling with a really good way to communicate that to patients so that they can see this input tweaks this metric, which then causes us to make this output adjustment. So we can do that in a very crude way. I think it produces good results. It would produce far better results if the patient could see it just the way they could see a dashboard of their car. That's not a very sexy or interesting thing, but at the level of our practice, that's very interesting to me. Another thing that's really on the forefront of what I think about is how to create the definitive training program for this idea of the centenarian decathlon, this mental model, which I maintain for most people who are no longer specializing in a sport or training for something in particular.

1:23:35If you're really thinking, what does it mean to be an absolute animal of an 80 year old who can function like a 60 year old, like a fit 60 year old, think about what that means. How do you train for that? And we're doing so much work on that. That just completely obsesses me. So that's the science of movement. That's the science of strength. That's the science of training and fitness and injury prevention and injury treatment and all of those things. Well, Peter, I think it's interesting that as you've described your purpose narrowing subjectively, that with the book and podcast and other stuff, your impact is probably growing, which is probably a good lesson there.

1:24:12I have learned so much from you over the years, but I do think that Outlive, the book, really distills so much of the incredible amount of hard work and thinking that you and your very talented team have done together. So I'm so thankful for the book. So nice to reconnect in this format. Just a total pleasure. I've learned a lot, like always. Thank you so much for your time. Patrick, thank you so much for sitting down with me and putting so much thought into this. If you enjoyed this episode, check out joincolossus.com. There you'll find every episode of this podcast complete with transcripts, show notes, and resources to keep learning.

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