Ep 54: Peter Attia on the Science of Longevity, Willpower vs Environment, and Why Americans Are Increasingly Unhealthy

0:00If you're willing to commit to, you know, a really serious exercise program, which again, doesn't mean you're killing yourself, crushing it, running a marathon every weekend. It means if you're paying attention to a portfolio approach of strength, stability, aerobic training, anaerobic training, all those things, you know, it can add up to a decade to the length of your life. And more importantly, and I say this to my patients, if all this exercise shortened my life by a year, I'd still do it because of what it's giving me in quality of life.

0:33My friend Peter Atiyah is one of the most famous thinkers in healthcare and longevity. He has a very popular podcast himself. Let's find out why a lot of the most successful people in the world are flocking to Peter and getting his advice. Excited to have Ryan Holiday with me here today and our friend, Dr. Peter Atiyah. Peter, thanks for joining us. Yeah, thanks for having me, guys. Let's start with your background. You graduated from Stanford. You were named Resident of the Year at Johns Hopkins, and you left your residency early. You weren't having it, and you've become obviously a very famous doctor doing a lot of amazing things.

1:00Why did you leave your residency? What was going on? A lot of things. I was just unhappy with kind of medicine in general. Didn't feel like I was having an impact. Felt frustrated by a number of things. Felt that the system of medicine at the time was not very innovative and really moved at a very slow pace. And also, I think, frankly, there were just other things that were frustrating. I really did miss quantitative things. My sort of quantitative areas. And I just had an itch to sort of do something totally different. So actually when I left, I left and, you know, went and did consulting and worked in finance and completely left medicine for some period of time before coming back to it.

1:42You know, you've dedicated yourself to science of longevity. You've become one of the great kind of thinkers in that space and testing all sorts of things. Like how'd that get going? Actually, the seed that sowed it was actually the birth of my daughter. So that was, you know, 14 years ago. And I think, you know, you guys can both relate to this because you both have kids. I do think there's some gene that starts getting transcribed the second you have a child. And there's just a shift in thinking. And all of a sudden, mortality became something I considered and contemplated. And wanting to live longer became an interest, which previously it really hadn't.

2:17All I had cared about was sort of performance. And you're unique in this because you not only teach the science longevity, but you experiment on yourself. You test exercises, diets, training regimens. Did you start doing that right away when you started becoming interested about it? Yeah. Yeah. I mean, I think that's sort of how everybody kind of gets into things as they, they start tinkering on themselves and then you realize, well, there's only so much you can sort of figure out this way. You have to understand more broadly what the science has to say. And then how does that apply? You were an ultra endurance athlete.

2:44You have really intense fitness regime. Is this still something you today? Is that healthy to be, to be super intense athlete for what you do? I mean, I think it's very, it's a relative question. I think some people would still look at me and say, I'm pretty intense and extreme. I would say by the standards of what I did from the ages of 13 to 44, I would say I'm the least extreme I've ever been, but my focus is very different now. I mean, I would say that, you know, my focus is much more on how to be the best 80 year old or a hundred year old. Yeah. But it's, it's, I'm not, I'm, I'm certainly not focused on being the best 50 year old.

3:20There's nobody who walks up to me in the gym today who would say, wow, what are you doing different? You know, cause it's not, that's not really. So what does that mean? How do you get to be the best? Like there's something called the centenary Olympics. I think you mentioned that you want to be able to compete. Like what are how do you get there? And what are the types of things you want? Yeah. I mean, I have this term called the centenarian decathlon, which is mostly just a, it's a mental model, right? It's just a way, it's not an official event, of course, but you know, what, what is it about decathletes that are relevant?

3:46Well, they're generally considered the best athletes. Uh, you know, the person who wins the decathlon at the Olympics is generally regarded as the best athlete. But individually, they're not great at any one sport. They're not the best at the sprints or the hurdles or whatever it is. But in terms of their well-roundedness, they are. And I think that's actually an appropriate way to think about what it means to be an exceptional 80-year-old, 90-year-old, or amazingly, if you can get there, a hundred-year-old. Good at everything. Yeah. You have to be very good at a lot of things. Ryan's latest book is called Discipline is Destiny.

4:17Discipline's a big part of this. How do you think about that? I think for some people it is. For me, it's not. I mean, exercise is, you know, the discipline is to not exercise more. The discipline is to, for me personally, is to, you know, spend time doing other things. Very unusual, probably. Perhaps. But that's still discipline. You strike me as, you're talking about intensity. You're an extremely intense person. So in a weird way, letting that intensity run amok is a lack of discipline. That's right. And to be able to say, hey, also, I don't want to be all these things at 50 that come at the expense of what I want at 70, 80, 90, 100.

4:50Yes, I would agree that I probably exert more discipline in my life around exercise today than I did 10 years ago. And I mean, I give you an example. I had shoulder surgery for an injury that's older than I am, basically. Should have had the operation 15 years ago. Finally had it six months ago. and I have, I'm proud of myself in the regard that there are times when I'm deliberately slowing myself down in the return to, you know, doing pull-ups again and things like that, where I think the Peter of old would have said like, you have to get back to doing as many as you were. And now I'm like, no, play the long game.

5:22You don't have to do them all today. I want to push back on this a bit. The last time we hung out for an hour, we was really hot outside and we had a ton of weight on ourselves and we were walking. That seems pretty intense. Is that, not a little bit intense to actually that ties right into this guy here so that what you're referring to is rucking which is one of my favorite activities so this is an exercise taken straight from the military this is a very important part of how people train in the military so carrying heavy weight is just a very important part of training and if you talk to especially special forces guys they'll tell you like this is you know the stuff that they do is legendary 24 hour march with half your body weight on your back so it's like caesar's legions huh is that carrying all his weight around over the Alps.

6:01So what we were doing was a third of our body weight, which I think is really all you need if you're a regular guy. But what I really love about it is it's half physical and it's to me half emotional health. So, you know, Ryan wrote a book called Stillness and I think it's one of my favorite books ever. And it really left an impression on me, which is that there is no substitute for being in nature, not having electronics, not listening to something because I'm always multitasking, right? I'm listening to an audio book or a podcast, but there's, I don't bring the phone with me when we do that exercise.

6:34And sometimes I have a friend with me like that day you joined me, but most of the time I'm alone and it's just looking at the fractal geometry of the world, hearing the wind. Um, and, and an hour of that, I think, you know, you're, you're getting this amazing physical benefit of the challenge of it, but, but I think you're just getting as much of a psychological benefit. It's a, it's a meditative thing. It's physical and you're in shape for it, but it's your mind that actually emerges stronger and more refreshed. Yeah. And I do different things. There are times when I will focus on an object.

7:08So one of the things I really think that's interesting, most people aren't aware when you're walking, you're generally not aware of the wind hitting your fingers as your arms swing, because we walk and we swing our arms. But if you tune into that, you'd be amazed at how profound that wind is on the leading edge of your hand as you walk. And so there's times when I'll spend half a mile and that's the only thing I'm thinking, all of my energy is focused on that one little thing. And in that sense, it's a highly meditative process. Is meditation important for longevity? Is it important in some way it's tied to whatever things you do?

7:42I mean, I think it depends, right? I think for some individuals, it's probably an essential part of who they are. I don't think meditation per se is essential in the way that I would say exercise is essential and reasonable nutrition and adequate sleep are essential. There is no replacement. I mean, meditation is a tool that for many people can be a really valuable way to improve quality of life. And I think having a high quality of life, having a good emotional life is essential for longevity. If we define longevity to include healthspan. What's lifespan versus healthspan? How do you think about that?

8:13Yeah. I mean, lifespan is the obvious sort of binary part of this, right? Which is like, you're alive or you're dead. So that's the digital piece. I think the analog piece is the harder one to sort of describe, but that's the health span piece. That's the quality of life. And I think there are three metrics. I think there's the physical side of that. So are you free from pain? Do you have muscular strength, muscular endurance, cardiorespiratory fitness, all of those things? And then there's the cognitive side. So do you have good memory, processing speed, executive function, all of the things that define you guys.

8:43And then the, I think the arguably the most important, but the least easy one to quantify is the emotional health piece, right? So what are your, you know, are you, are you fulfilled? Do you have a sense of purpose? Are your relationships good? All of those things. And I, and I think again, to have the others without that is, is purgatory, right? How much of all of this is determined by genetics ahead of time? A lot of these are like genetics first and then you can modify them. No, not many. I mean, look genes play an elaborate role in ultra longevity so your grandmother's like how old 102 and she's doing great right now so so that is almost exclusively a genetic lottery um so once you're in the 90 plus category genes are almost entirely all responsible but if you start eating lots of bacon and stuff that she's honestly like if you look at she's Yeah, yeah.

9:35So if you look at, you know, Tom Pearls and Nir Barzali, who probably run the two largest cohorts of studying centenarians and their offspring, I mean, on average, centenarians exercise less, smoke more, eat worse. They just have good genes. They just have fantastic genes. If you get away from that, again, I don't think you need to win the genetic lottery. Now, look, you can have some real genetic curses. There's no question there are people that, you know, have a very, very strong history of cancer in their family, for for example, or, you know, there are very fortunately rare examples of people who have, you know, genetic predisposition to Alzheimer's disease, for example, you know, 1 % of people who get Alzheimer's disease get it in a deterministic manner, meaning they literally get one of three or four genes that guarantees you'll get it.

10:18But for the most part, I don't think this stuff is genetic. Now, there is actually some evidence that happiness and a person's sunny disposition has a pretty reasonable genetic component. So I don't want to dismiss genes, but I also think we, I think we dwell too much on genes sometimes. And I think we should just probably focus on what we have control over. I saw a commercial that reminded me of you. You've probably seen it. It's this old man and he's practicing with a kettlebell doing, you know, squats or whatever. I saw it on Twitter. So is it an actual commercial? Yeah, it's a commercial. I forget what it's for.

10:50He's fantastic. And this makes me think of Healthspan. So he's doing it and then you find out Christmas morning or something, his granddaughter runs in the room and he's been practicing lifting the kettlebell so he can pick his granddaughter off the ground. And so it's not just the physical component, right? But it's also, have you lived your life? Have you made decisions? Do you have the personality that makes your granddaughter want to spend time with you, right? And so, you know, you could be the fittest 100-year-old in the world, but if you're a curmudgeon or a jerk, or you put work and money and all these other things in front of family, there's nobody who's going to be wanting to run into your arms.

11:27I mean, I couldn't agree with that more. And one of the things we do with our patients is I try to explain, and I use an archery analogy for this, which is we talk about what are your long-term goals? Your long-term goals is your marginal decade, the last decade of your life. So how clearly can you define what those are? And then what are your goals for the next 12 months? And as you know, because you now shoot a bow, have you ever shot a bow? Yeah. So in archery, you have the sight at the far end of the bow, and then you have the peep, which is on the string that you pull to your eye. And so when you are in full draw, what's happening?

11:59You are trying to acquire rear sight, front sight overlap perfectly. If those don't overlap, you will miss. If those are in perfect alignment, you will hit. And the same thing is true. If you say, oh God, in my marginal decade, like I want to be surrounded by love and family and great grandchildren, and I want to be able to lift them up. But in the short-term goals, you're not doing anything about that. You're not going to miss, right? You're not going to hit the target. We were talking about hobbies earlier. Bow hunting is obviously a hobby for you. Is that another thing that gets you into that sort of meditative place that ratchets down the intensity that is an outlet for some of this stuff?

12:36Yeah, totally. I mean, I just, I love things that are precise. And that's, you know, archery is a very precise thing. I don't play golf, but I would imagine it's very similar to golf, but it's also something that requires great emotional control. So yesterday I was shooting and I mean, I was just having a really bad day. I mean, I know today, nevermind yesterday, it was this morning. I mean, I was horrible. And I think what I love about that is I have to control my emotions. You're nervous about the podcast coming up. And, you know, I think like five years ago, I would have thrown a little mini temper tantrum about how bad I was doing.

13:16And today it was just like, huh, this is really interesting. Let me be curious and not judgmental to borrow from Ted Lasso. And let me kind of like, think about like, why am I doing so badly at this today? And can I make an adjustment? Oh, I did. Okay. I didn't make anything better. Okay, fine. Make another adjustment. Oh, actually I did get better. I got a little bit better. And then I got a little worse, but you know, that to me is actually a practice. Like that's a skill that I mean, it's almost embarrassing to say this, but there was a day when if I shot poorly, I had a bad day. Like, can you imagine that?

13:48Like, that's pretty weird to think that you could go out in your backyard, shoot a bow and arrow for 45 minutes. And if it didn't go well, the rest of your day sucks. The hobby shouldn't ruin your day. It should improve the day. That's right. It's like when you play golf or something and you have a really bad golf game, try not to let it ruin the day. Right. And, and so, you know, today something I can be very proud of is like, that's no longer the case. It just doesn't matter. I can have the best day. I can have the worst day. By the time I drop the bow off in my man cave, like I've forgotten about it.

14:14Also, it's another thing that forces you to be present, disconnects you from the phone, the device, things not going well, going well. It forces you outside doing a thing that I think the reason it's not going well is just another benefit, which is that it's humbling. It doesn't matter how long you've been doing it. It doesn't matter how talented you are, how smart you are. It's hard. and therefore beneficial from an ego perspective because it makes you realize you're not the master of the universe, even if you are professionally master of your universe. I remember walking back today from the targets after pulling and I remember just thinking like, this is amazing how hard this is.

14:56It's amazing that this is just really, really hard. This ties a little bit into kind of self-control, virtue, discipline. If you look at the data right now, America's health overall is in a very bad place. Life expectancy has actually gone down recently. Antidepressants, obesity is going up. You study this closely, like what's happening? How can we reverse these trends? Is it partially as virtue? Is it something else? That's a great question. I mean, we know that there are two things in the past three years that have tipped the curve on life expectancy in the United States. So the first of these is the opioid crisis, which is obviously a mental health crisis first and foremost.

15:33So we talk a lot about what is the number of deaths from suicide. And that's, believe it or not, for everybody over the age of 10, suicide is the only cause of death that is always in the top 10 by decade. The only decade for which it's not a top 10 cause of death is under the age of 10. So think about that. 10 to 20, 20, 30, all the way up to 90 and up, suicide is the only thing that is in the top 10 across the board. Was this the case 50, 100 years ago? I don't know. That's a great question. I should know the answer to that, but I don't. But here's my point is that suicide only barely captures it because if you look at accidental deaths up until the age of 55, even probably 60 now, the hands down leading cause of accidental deaths is now overdose.

16:18So that has even exceeded auto deaths in young people, which was formerly the leading cause of death. These are deaths of despair. That's exactly right. These are slow suicides. And so, you know, that has taken an enormous chunk out of our life expectancy. The other one is probably a bit of an artifact, which is COVID, right? COVID, I think probably sped up the demise of a demographic of people who were sick on average, right? So, you know, lots of people have died of COVID who weren't sick, but the majority of the deaths attributed to COVID are people who were probably going to be dying in the next five years.

16:54Vulnerable people. That's right. And so therefore, I don't know how that will reflect in the next decade, but what I don't see a trend to reverse yet is the first thing I said. And that's to me, the kind of elephant in the room. What about the obesity epidemic? I mean, we have this whole body positivity movement, which I think is very unhealthy. It's very controversial maybe to say that, but it just seems like there's a big issue in our society where we're trying to say, oh, certain things that are bad for you are okay or are good or don't criticize. Is that contributing to this as well? I just don't know the data truthfully.

17:24I mean, my view on these things is these things really like we shouldn't really, I'm not interested in the subjective. So I think there's a subjective part of this that I just don't have a voice on or a view on because it's very personal. Like I, you know, I personally wouldn't want to be a hundred pounds overweight. That's just me. Uh, it doesn't mean that a person who's a hundred pounds overweight is any less of a person than me. I just wouldn't want to be it. Um, for me, what is objective is what is the impact of that weight on health? That's really the question that I'm concerned with. And I think there were basically two ways to think about that.

17:56And it's through what we talked about earlier. What's the impact on lifespan? What's the impact on health span? And at a low level, there's actually something called the obesity paradox, right? So a low level of obesity actually seems to be somewhat protective in an aging population. When you're older, having a little bit of extra weight, it's not necessarily bad. That's correct. That's correct. That's referred to as the obesity paradox. Now, I also think that the problem is obesity as defined by BMI is such a crude metric that it's very difficult to really draw much of a conclusion. You know, when you look at somebody whose BMI is 31, like, I mean, my BMI, I don't know what it is, but it's clearly in the overweight category.

18:36Yes, BMI is so strong and you have more muscles. Well, I mean, I just think that BMI is like 25 is considered normal. I'm probably like 28 or 27. And so we wouldn't even consider that metric in a patient. I couldn't tell you the BMI of one of my patients. I'm trying to build muscles as a friend. You told me I should do that. It's healthy. I'm having all this beef jerky recommended. And so it seems like that's probably going to be my BMI goal. Yeah. So what we would care about though is how much visceral fat do you have? Not even body fat, just visceral fat. How much fat do you have around your organs?

19:05Because that's actually the metabolically damaging fat. Are you insulin sensitive or insulin resistant. You have metabolic syndrome. Those are actually the metrics that matter. And, you know, look, those metrics are pretty bad. So I think right now, you know, I was just kind of going through some of these numbers for, as I was finishing my book and the most conservative estimate I can come up with, and there are many higher estimates out there, but if you're taking the absolute floor, it would be a hundred million American adults are metabolically unhealthy. Wow. So that's the problem. I wish that's what everyone would talk about.

19:40Yeah, I imagine despair is part of that as well. Totally. It's like, what, like 70, 60 % of young people could not join the military if they wanted to because they're so out of shape. They're not fit enough, yeah. And you think this part of that, I mean, a big part of it is obviously terrible, you know, food system and people don't have access to healthy, blah, blah, blah, blah. But a big part of it is this is a person who does not think they need to be healthy for any real reason. And they're not they're not being put to use in a way that would make them feel like they are not being purposeful with the decisions that they're making.

20:20Doesn't that come back to virtue and positive masculinity and like your role as for women as well, your role in society? Like, just focus on men for a second. There's a lot of stuff I've seen about declines in testosterone levels. Like, what's happening with that? Is that tied to this? I'm not sure. I mean, I think there are probably lots of things that can explain, you know, a fall in testosterone. So, you know, not sleeping well is going to have an enormous impact on testosterone. So then you want to think, what are the things that impact sleep? How much of it is being on phones, putzing around, like, you know, drinking too much, smoking too much pot, which may or may not.

20:52Twitter and video games late at night. Basically, it's like there are lots of things that if done to excess, like I'm not going to sit here and say don't drink alcohol. I'm not going to sit here and say like, you know, you should never smoke pot. I mean, that's neither here nor there. I'm just saying there are things that if done to excess will impair your ability to have a normal set of hormones. And I think that's probably the issue more than anything else. It feels like the self-control thing with the obesity as well, as both of these things are tied to some form of temperance almost. Well, yeah, except that I think, I don't believe that there has been an erosion in self-control over the last 40 years.

21:25So this is the million dollar question, right? So why is it that 40 years ago, obesity rates, and again, I just said a moment ago, obesity is the dumbest proxy in the world. But I'm going to assume that as much as obesity rates have gone up by two to three X in the last 40 years with it has gone metabolic health. So given that that's, we use the proxy. Okay. I don't think that 40 years ago, people had that much more willpower than they do today. I just think that the environment has gotten so much worse that you would need more willpower today to fight the gravitational pull of this environment.

21:58So 40 years ago, I think, or let's just even say 50 years ago, because I can tell you 50 years ago when I was born, less than 2 % of people in the United States had type 2 diabetes. It was closer to 1%. That number is about 12 % today. So when you have a log fold increase in 50 years of one of the most devastating diseases, you have to ask the question, is this a failure of personal responsibility more or is it a failure of the environment more? And while it can't be one exclusively over the other, I actually attribute more of that to the environment. And I think that environment is not just the grocery store is packed with more awful stuff, but also if people feel worse about things, they're more depressed, if they have less purpose, if they feel like they're left behind, you know, again, why does it matter whether I'm in shape or not?

22:46I'm not of use regardless. I guess social media or whatever can make us more isolated and then we don't see our community and then that could lead to that, which is the problem. I think it's a death by a thousand cuts. I really, you know, and I had an email chain with some friends recently about this where there was a symposium in Europe where they got all the biggest obesity researchers in the world together. And the New York Times wrote a piece on this that basically said, well, we just had basically all the smartest people in the room for a day and they literally couldn't agree on one thing.