How to be fit forever with Peter Attia (E212)

0:00Before we get going, just a quick reminder that you can download the High Performance App for free. download the app use your exclusive code h p app that's hp app for access where you can hear simon cynic guiding me through a process to help me find my why just download the high performance app for free and use the code hp app for access hi there you're listening to high performance the award-winning podcast that unlocks the minds of some of the most fascinating people on the planet I'm Jay Comfrey, and alongside Professor Damien Hughes, we learn from the stories, successes, and struggles of our guests, allowing us all to explore, be challenged, and to grow.

0:43Here's what's coming up today. If you want to live longer, by definition, you have to delay death. The four horsemen really are the adversaries you're going up against in the length of life part of the discussion. If you understand that those are the horsemen and you want to live longer, part of that strategy is what drives each of them and what do I need to do to delay their onset. The seeds that you sow in your youth are the same flowers that come to harvest later on. Sometimes you're eating at a rate that exceeds your ability to sense appetite. The data would say that nutrition does matter, but it's not nearly as important as exercise.

1:25If there's a person who's listening who's saying, I don't know step one, then I would say, maybe it doesn't matter. How about just pick one? Is my eulogy going to be better than my resume? So welcome to a conversation with Peter Attia, MD, the founder of Early Medical and someone who practices medicine 3.0, which is really looking at life, not through the lens of when you're ill, how do you get better? But how do you stop yourself from getting ill in the first place? Peter actually left medicine feeling frustrated, but since then he's gone on to host The Drive, one of the most popular podcasts covering health and medicine in the world.

2:01And he's just released his most recent book, Outlive, The Science and Art of Longevity, already a New York Times number one bestseller. And he talks to us today about innovative nutritional interventions, techniques for optimizing exercise and sleep, and tools for addressing your emotional and your mental health. We talk about the fact that in the last decade of someone's life, they need to still have the quality of life to actually make that the best 10 years they've ever had he's on a quest to do that and he's also on a quest to help you be healthy forever here he is peter attia md on the high performance podcast

2:47peter thank you very much for joining us gentlemen thank you so much for having me What is high performance? For me personally, it's shifted so much. So it used to be about the here and now. It used to be about my performance in cycling or boxing or whatever it is that I was doing. Today, it's 100 % focused on what does my performance look like in the last decade of my life. If I can be sure that that is exceptionally high performance, I'm confident that everything I'm doing before then will be at the highest level it can be. Look, we want this to be the ultimate conversation really for your average listener to a podcast to hear a conversation and feel empowered to do something about it.

3:32So what would your message be at the very beginning to those people who are already thinking, ah, a doctor, an expert in wellness and health and fitness and longevity, like, is this really for me? You know, surely my time on this earth is fixed. What would you say to the people who are coming to this conversation with that kind of mindset at the very start? So I think there's two things, right? I think one, your time on this earth is actually not really that set in stone. I think there is some malleability to it. But I also don't believe in science fiction. So I don't think that there's some people out there that say, oh, we're going to be immortal and science is going to cure everything.

4:07Or at the opposite end of the spectrum, none of this stuff matters because your genes are your destiny. Neither of those extremes are true. We can move the scale quite a bit. but the thing that really isn't remotely fixed is the quality of your life. That's the part that everyone's born with pretty much a clean slate, no matter what their genes might speak to as far as the length of their life. And if a person really focuses on the quality of their life and takes that as the most important metric, as opposed to say the length of their life, I just don't see any reason why that shouldn't be the highest focus and why, by the way, when you do that, you get bonus time as well.

4:46You do actually extend life by focusing on quality. What are the kind of questions that we should be asking you to help our listeners understand about how they can improve the quality of their life? Look, I think you guys know your audience the best. What would you want to know? The first thing that I would feel is improving the quality of my life is complicated because I feel there's a million bits of information out there. I don't know whether I start by eating better, sleeping better, lifting weights, doing cardio, spending time with my kids. I literally would not know step one. You've actually picked up on all the things that do matter and all the things that you have some control over.

5:26If there's a person who's listening who's saying, I don't know step one, then I would say, maybe it doesn't matter. How about just pick one and get a win? We could debate which one you should pick first, but that's a second order question. Maybe the one you pick first is the one for which you have the greatest opportunity to succeed. Maybe the answer is right now I'm not doing well on any of those things. How about I just start figuring out a way to be active 30 minutes a day? That's the one I'm going to put some success into. And after a couple of months of doing that, I'm definitely going to feel better.

6:00And that's probably going to empower me to maybe eat a little bit better. And maybe along the way, I also realize, oh, I could probably be a bit more present when I'm home. How about when I'm at home, I put my phone away and I just decide for an hour when I get home, all I'm going to do is talk to my wife and my kids and not be glued to my phone and checking my email and looking at social media or whatever. So again, I just don't think there's like a right way to a wrong way to do this, but I do think that it can be overwhelming if you try to do everything. And I think for most people that doesn't work.

6:33I used to try to do that with our patients. I used to sort of say, all right, well, here are all the things that we need to do. Let's do all of them in parallel. And there's probably some people for whom that works, but I think for most people, that's really overwhelming and it can actually set them back. So I would much rather a person start slow, become successful, gain confidence, and then start adding to it. So that's a great place to start. I'm interested in the why people should even start on that journey. And you speak around the four horsemen of the apocalypse in terms of our lives. Would you explain what they are so people could understand why starting is such an important imperative?

7:18You know, the word longevity gets thrown around a lot and it's a bit of a confusing word because I think sometimes people hear longevity and they just think about how long they live, or maybe they just think about quality of life, but really it's all of those things. So longevity really speaks to lifespan, which is how long you live and healthspan, which is the quality of your life. The four horsemen really are the adversaries you're going up against in the length of life part of the discussion. If you want to live longer, by definition, you have to delay death. to delay death, it makes sense to understand what drives death.

7:58And in the world today, this is not true 150 years ago, but today we die from chronic diseases. And if you exclude smokers, and I am excluding smokers from this because yeah, I realize a lot of people smoke, but usually the people who are smoking are not the ones that are interested in longevity. So let's just simplify the analysis and say for a non-smoking population, what are the things that are going to kill basically 80 % of them? It's going to be heart disease, cancer, what are called neurodegenerative diseases of which Alzheimer's disease is the most common. and then all of the metabolic diseases that run the gamut from something called insulin resistance all the way to type 2 diabetes.

8:43If you understand that those are the horsemen and you want to live longer, part of that strategy is what drives each of them and what do I need to do to delay their onset? Because that's the magic in having a slightly longer life. Not an infinite life, but you can live 10 years longer by delaying the onset of those diseases. because we're obsessed with finding out whether we're ill and if we're ill treating the illness this is a very different way of looking at health isn't it this is treating those illnesses decades before you even have them exactly the problem with those diseases is that they differ a lot from a ruptured appendix or pneumonia.

9:29Those illnesses, you can treat them when they show up. This is not an opinion. It's simply just an observation of fact. We have made virtually no progress on extending life by treating chronic diseases in that fashion. This is kind of stark. And in fact, I think it's so, there are very few pictures in my book because you know, there just wasn't enough room to put all my favorite pictures in. But this is one of the pictures that's in there, which is a figure that shows what human mortality has looked like in the developed world since, oh, about 1890 or so, 1880 until today, with and without the inclusion of infectious diseases and communicable diseases.

10:18So if you just look at all diseases, life expectancy has gone from about 40 to about 80 years. We've about doubled lifespan by taking care of these acute illnesses. If you strip the top eight causes of communicable and infectious diseases out of the analysis, it's a flat line. We have not extended life very much. So that tells you right there that we're doing a little bit. I don't want to suggest that people don't live longer today because we have better treatments for heart disease and cancer and things like that. We do, but it's not dramatic. It's not like decades of difference. You talk about five pillars of health in your book, which maybe can make the difference.

11:04Maybe for someone listening to this podcast, this could be the conversation that makes the difference for them or their parents or their children. Who knows? Can we, can we go through them? Yeah. So the, the five things that I think constitute the activities or the pillars, the vectors, you can talk about them. So one of them is nutrition. So basically what you eat, when you eat, how much you eat, all those things factor into your health. Exercise and movement, sleep, all the things that you do around managing your emotional health. And then the final one is all of the molecules, pharmaceutical agents, hormones, supplements, drugs that you would take.

11:42I call that exogenous molecules is just a fancy way to describe that. Exogenous means from outside the body. Makes you sound very clever. So those are your big five things that you have control over. Okay. Can we go through them individually? Sure. Let's start with nutrition. What would you share with us about nutrition? The data would say that nutrition does matter, but it's not nearly as important as exercise. What do we know about nutrition? Well, we know that too much of it and too little of it is a problem. But we also know that for most of human history, the problem was on the too little side, right?

12:19If you go back 200 years, 300 years, 400 years, I mean, for most of human history, we didn't have enough food. And so how did our species get here? I don't think anybody would dispute the fact that we are sort of the apex species of this planet for better or worse. And what enabled that was really the development of our brain. Like we're not the biggest, We're not the strongest. We're not the fastest. So why do we run the planet? We run the planet because we're the smartest, right? We have the most advanced brain and the brain is a very energy demanding organ. It's, it's, it's actually staggering, but you know, your brain makes up about 2 % of your body weight and it's consuming about 20 to 25 % of your total calories.

13:03So for us to have the brain we did in a nutrient scarce environment, which is what the world looked like for 99 and 0.999 % of existence, we had to figure out something important. And that something important was how to store energy. So this is something where humans have become really good. We are very good at storing energy. And most of that energy we store as fat. We can't store much carbohydrate and outside of our actual muscles, we don't really store protein. So every excess calorie we have, we store as fat. And up until very recently, this was not a problem. This was a very good thing. It's only a problem, like I said, roughly in the last hundred years, where energy and food have become so abundant that we now have too much.

13:53So evolution was solving a problem that existed for hundreds of thousands of years. It had no anticipation of the world we live in today. And so now most of us are walking around with too much energy. We're storing too much of it. And that excess amount of energy is indeed problematic. And it is underpinning so much of the disease that we have. All of those diseases we talked about, those metabolic diseases, the insulin resistance, the type 2 diabetes, those are diseases of excess energy. And they amplify the risk of every one of the other ones we talked about of the other horsemen, right? So that's amplifying your risk of heart disease, cancer, Alzheimer's disease, dementia, etc.

14:31etc. So for many people listening, and frankly for myself included, the bigger issue is excess energy. So it's how do we eat less? And it's not just eating less of everything. It's primarily eating less in terms of total energy, but not eating less protein. Because the other thing we have to manage with nutrition is making sure we get enough protein to support our muscles. We'll come to that more in the exercise discussion. But with nutrition, it's very challenging because, again, we're trying to figure out a way to eat fewer calories without restricting protein. So how do you eat fewer calories?

15:08If the objective is eating less, you have three strategies to go about doing it. The one is directly doing it. So I talk about that and I call that caloric restriction. You can just say, every time I eat, I'm going to pay attention to what I'm eating and I'm going to reduce the total amount. There's something called dietary restriction where you just say, I'm going to limit certain things that I eat. So I'm going to stop eating meat or I'm going to stop eating carbohydrates, or I'm going to stop eating this or stop eating that. And the more restrictive you make that, the more you tend to restrict calories along the way.

15:42And then the third strategy is time restricted eating. And that says, I'm going to restrict the window in which I eat. So I'm going to make it smaller and smaller so that I can basically eat less and less. Some people call that intermittent fasting. And those are basically your three strategies. Each one of them has a strength and a weakness. I talk about that in the book, which one might be right for you and they can be combined. Which do you do? Mostly dietary restriction for me. I'm more conscious of what I'm eating than when I'm eating or how much I'm eating. But I've done all of them to extremes.

16:16So I can speak to all of them in extremes. I mean, I've gone through phases of my life where I was incredibly calorie restricted, basically every month going three days without eating and every three months going seven days without eating. I've gone through periods of my life where I've only eaten one meal a day. So, you know, I've gone very extreme on all of these fronts. And truthfully, if I'm going to give myself a grade on eating, like I don't put nutrition as my A, like I'm not scoring A's in nutrition. I'm probably a B student. I mean, that fits with, we interviewed a Spanish academic called Hector Garcia that has lived out in Japan for many years.

16:52And he's written a book around long life in some of the Japanese communities. And the conversation was around the concept of Ikigai. And one of the things that they talk about there is that they have an 80 % rule that when you're 80 % full, stop eating. Yes. I think that's a fantastic rule, by the way. And I'm constantly amazed at how much better I feel if just before I'm full, I stop eating and wait a minute. And sometimes, and I don't know what this comes from. I think it kind of comes back to my medical training when you never knew when you'd get to eat, uh, or if like a trauma was going to come in and you weren't going to get to eat.

17:31I developed this awful habit of eating incredibly fast. And sometimes you're eating at a rate that exceeds your ability to sense appetite. If you can be kind of mindful when you're eating and pay attention to your appetite, I think you can end up in this great place. And I think that's absolutely brilliant advice. So can you also offer us some advice that you do touch on in the book for anyone listening to this, that is maybe thinking one of the first pillars that I'm going to address is nutrition when they walk into a supermarket, because one of the things you acknowledge is the fact that our brains have created a system where we can store food, we can make it tasty, and we can make it in surplus all over.

18:18So when we walk into a supermarket, where do you advise that we should be shopping from? Yeah, there's two pieces of advice I have here. So the first is actually don't grocery shop hungry. Because I think most people who have done this will recognize that you will make worse choices when you're hungry than when you're not. You know how the brain has three parts, right? You have kind of the brainstem and then the midbrain and then the upper part, which is the most advanced part of the brain. Okay. The lowest part, the brainstem is kind of responsible for like, you know, eating and, you know, like digestion and all of those things.

18:53Right. So you want the most advanced part of your brain doing the grocery shopping, not the least advanced part of the brain. So take that part kind of offline a little bit. The second piece of advice is if you can just walk the outside perimeter of the grocery store and only buy what's there and not go up and down the aisles, you're going to do a lot better. Because what you're probably going to end up eating is vegetables, fruit, meat, eggs, dairy, cheese, like you're going to not get into processed foods very much. Whereas if you get up and down the aisles, you're going to end up in a lot more processed food.

19:33Now, look, not all processed food is necessarily harmful. It's much more nuanced than that, but it becomes a very convenient, you know, heuristic to just simplify your life a little bit. If you're trying to think like, am I better off having yogurt or chocolate pudding? You're probably better off having yogurt, right? That's a great tip. Thank you. The problem I guess with nutrition is that, you know, calories, for example, don't tell us the whole story. So drinking Diet Coke doesn't give you any calories, but it also doesn't do a great deal for you. My biggest issue, and my wife is exactly the same, is trying to be really well behaved all day, being, I think, probably calorie deficient come the end of the day, having some raging hunger about 9 p.m.

20:15And I'm attracted to the crisps, kind of getting over these kinds of hurdles. Now, hang on, hang on. Are they at home? Are you at home when you have these cravings? Yeah. So this is another thing that I go back to is, and I'm not saying this from a place of judgment because we have the same issue at our house. But I mean, I have three young kids. And so our pantry today looks much worse than it did 15 years ago before we had kids. And that's one of the challenges. But one of the struggles that my wife and I have is how can we have the fewest bad food choices? Because I think there's this important concept of how can you spend as little time relying on willpower as possible and spend more time letting the default environment set the stage?

21:01So if you're hungry at 9 PM and there is no biscuit and there are no crisps and there's like fruit and carrots and stuff like that, you'll nibble on them a little bit. You're not going to overindulge in that stuff. You simply couldn't. the reality of it is like if i have ice cream sitting in front of me i'm going to eat it too i think more about how can i put the right food choices in the environment so that i'm better so for example like today i'm carrying around like my venison jerky sticks and my nuts and that way it's like i don't have to eat something else but what if like someone brings out a beautiful chocolate brownie when we finish this chat and it's on the table out there well it's a lot easier for me not to eat it because I'm not starving.

21:47I think people sometimes want really simple solutions, but you have to understand there are two very powerful forces working against you. Evolution, right? We have a billion years of evolution that is trying to make us survive by eating all the time because that is in our best interest up until about a hundred years ago. And then on top of that, you have the commercial interests of what I call it in the United States. I call it the standard American diet, but the truth of it is it's the standard developed diet, which is very tasty, very energy dense, not nutritious, highly caloric, easily transportable.

22:27I mean, it has all these things working against us. If you have two very big foes standing in front of you, you should expect to do a little bit of work to get out of the way. And I think that's just the price we pay to live in a modern world that comes with many other benefits. Can I ask you a question, Peter, around, like you say, you've got three young children yourself and I'm a father too, as is Jake. And I sometimes despair when I see for the next generation, how easy and accessible and cheap some of these foods are that are not doing the next generation any favors. To get a 14 or 15 year old kid to almost think towards the end of their life is just too inconceivable for them.

23:12It's too abstract. Yeah. So what kind of questions, what kind of approaches would you suggest that we could use to get them to start to make better decisions without trying to frighten them or? I think it's focusing on performance. Like I know when our daughter was born, she's our oldest, I was much more fixated on my food back then. And I think that even today we pay attention very much to what we eat and what our kids eat. We pay very much attention to how much exercise we're getting. And by extension, we want them to do the same. Until I wrote this book, I honestly don't think my kids had a lick of a clue like what I did.

23:51They knew dad was a doctor, but basically what we get them to focus on is performance. So if you eat protein, you will be stronger. And, you know, our kids all play sports. So they get that like, oh, the way I eat impacts the way I perform. Okay. That makes more sense. You will have more energy if you eat this food versus that food. And I don't think we should shy away from that. I don't, I, you know, people say, well, oh, you know, is that sort of judgmental? And I'd say, yeah, it is judgmental and it's okay to be judgmental. It's okay to say that this food is better than that food. And it's okay to say that performing well is something we should aspire to.

24:33But I think you're right. I mean, I don't think my kids would even understand what diabetes is or what cancer is or what it means to live longer. I think that's so abstract and not particularly meaningful. And what are these modern diets doing to our bodies? This hidden cost, I guess. I think, unfortunately, nutrition science is still a very difficult science to draw enormous insights from. I wish I could sit here and tell you down to the molecular level, the particular problem with a soda versus a diet soda versus this drink versus that drink and this food versus that food. At the highest level, what we know unquestionably that is the biggest problem of the modern food environment is it drives us to overeat.

25:18And that is the fundamental problem. Everybody has the ability to store fat. If you didn't have that ability, that's a very bad disease called lipodystrophies. And it's a healthy thing to be able to do, provided you store it in the right place. So the right place to store fat is in the subcutaneous layer of tissue. So right under your skin, you have these fat cells, and that's where we like to be able to store fat. So think of your capacity to store fat as a bathtub. A bathtub has water that comes into it and water that goes out of it. So the water that's going into it is what you're eating. The water that's coming out the drain is the energy you expend.

26:01Some of that through exercise, some of that through movement, just daily living. Most of that, frankly, just by being alive. If you laid in bed all day, you would still be draining the bathtub because it requires so much energy just to live. If you are in balance, the amount of water going in is about the same as the water going out. No problem. You can have a higher level or a lower level, i.e. be more fat, less fat. If it's in balance, it's pretty reasonable. What happens is when that bathtub starts getting so much water in relative to what's going out that the water starts spilling over the tub.

26:40And now you can picture the damage that water could do in that bathroom, in that house. That's what happens when the fat cell is no longer in balance. When the fat cell is no longer in balance, fat starts leaking out of that subcutaneous fat where we're meant to store it, and it starts going in places where we're not meant to store it. The liver, the pancreas, into the muscles themselves, around the heart. When fat accumulates in those areas, that is the hallmark of disease. that's the underpinning of everything going wrong. That type of fat called visceral fat or, you know, fatty liver, intrapancreatic fat, that's what's leading to the inflammation and resistance of insulin in the muscles and all of these things that predispose the disease.

27:30So the real problem with eating potato chips or whatever other snacks that all of us love to eat is we end up eating a lot of them. And this is by the way, kind of controversial. It's not entirely clear why there are many different theories. So one theory is we just eat more of it because it tastes good. Okay. That probably explains some of it. Another theory is we just eat more of it because it's so low in nutrient density and our bodies are wired to get a certain amount of nutrients. And if the density of nutrient is so low, you have to eat many, many more calories to get the same amount of nutrient.

28:10That's possible that that explains part of it. Another theory is that we are hardwired to get a certain amount of protein. Again, evolutionarily, we needed protein. It was a very important nutrient. And again, today's food environment has a lot of diluted protein sources in it. You know, a lot of the foods that are most palatable to us are carbohydrates and fats, less on the protein side. So again, we might be overeating to indulge more of a need for protein. And then of course you have other factors like the less active you are, the more sedentary you are, the less your brain is able to sense the satiety factors, the factors that come from your gut to tell your brain you have eaten enough.

28:53those are actual chemical signals and the less active a person is the more those signals are blunted so there's just so many different things that are going on that are getting hijacked by eating quote-unquote the wrong foods and can we unpick this it's like at 44 if i've overeaten for 30 years of my life can i stop and reverse that damage absolutely yeah yeah that's the most important message perhaps. Yeah. I mean, this is, it's never really too late to kind of do something about this. Um, and, and there are lots of stories that you'll, you'll see. I'm sure anybody listening to us has, you know, seen these remarkable stories of people who have just, you know, completely changed their lives, right?

29:35They've, you know, been sedentary their whole life. They've been, you know, eating everything. And all of a sudden they just one day wake up and decide I've had enough or they have a heart attack or something catastrophic changes in their health. And they realize that's, you know, that's enough. So I'm interested in some people that might think they're living a healthy life or go, I'm not carrying a lot of extra weight. What's the hidden cost then? And how do we discover whether what we're doing is taking its toll internally? Yeah, no, it's a very good point you raise because the assumption is that your body weight is the best indicator of your health.

30:11The truth is it's a very crude indicator of your health. Now, the reason body weight is sort of the main metric that's used at the population level is it's kind of the best we can do. I mean, it's better than your age or your sex or your hair color, but like, don't confuse it for what good is. It's just the least bad thing that we can measure. In the United States, where we have a significant obesity epidemic, I don't know how significant it is here, truthfully, I would guess it's not as bad as the US. It's still bad. Yeah, I'm sure it's getting bad everywhere. But it's possible we would have, of the developed nations, the highest rates of obesity.

30:58About 20 % or so of obese people are actually very healthy. What I mean by that is, if you do the really deep analysis and look at all of those other things, Do they have liver fat? Are they insulin resistant? Are there triglycerides elevated? You go and do all that other stuff. No, actually 20 % roughly of people who are obese are quite healthy. And interestingly, of the people who are not obese, yeah, about 20, 25 % of those people are very unhealthy if you do the deep dive and look at them. And so for that reason, we don't really spend a lot of time looking at a person's body weight or BMI.

31:39In fact, I don't think I could tell you how much one of my patients weighs. It's simply not a metric I care about because we're just going to immediately go and look at these other things. We're going to look at how much muscle mass do you have? How much fat do you have in your liver? How much fat do you have around your organs? What are your insulin levels look like? What's your blood glucose look like? How high are your triglycerides? We're going to look at all these other things, blood pressure, that are much more indicative of your health. So let's move on then to something which is absolutely linked to this and really important, the next pillar of health, which is exercise.

32:14Can we talk about your concept of being an athlete for life? I've always been sort of heavily focused on some sort of physical goal for all of my life, at least going back to when I was about 13. And as such, you're always training with some sort of specificity. So if you're a footballer, you have a very specific way that you train and it wouldn't just be go out on the pitch. You would still probably want to be doing some running. You would still want to be doing some strength training. You would still want to be doing some agility work. You would still want to be doing this type of conditioning, that type of conditioning.

32:45So the training of the best of the best is very specific. And when I was in my early forties and I kind of hung it up, uh, the last sport that I did sort of competitively was, was riding a bicycle. And, um, you know, when I decided I'm not, I don't want to do this competitively anymore. It's taking up a lot of time. My second child had been born and I was traveling so much more for work. So then this turned into this idea of the centenarian decathlon, which is I'm going to create the objectives. I'm going to define what the activities are in the last decade of my life. And I had to put a lot of thought into this.

33:23Like, what do I really want to be able to do? In other words, what are the non-negotiables? What are the things that if I can't do these in the last decade of my life, I will be very disappointed. I will feel less alive. What are those things? And those would be different for the three of us, right? That the whole goal is to do this in a personalized way. Yeah. But this is what I loved about it in the book, because I think you, like you include 10 of, and you said it extends to 50, the list, but what kind of questions or how would you help our listeners to be able to come up with their own definitive list of what they'd like to be doing when they get into that final decade.

34:05I think there's two ways to go about doing this. Um, one way is to project forward and one way is to project back. Okay. Okay. So let's talk about both. So projecting back is if you are fortunate enough to know somebody in the last decade of their life, or you've watched somebody who you were very close to and you saw them during that period of time and they've died, can you put yourself in their shoes and ask these questions, right? What am I no longer doing that I used to do? What am I no longer doing that I wish I could be doing? So you sort of work your way from the back to the present. And I think this requires being quite circumspect and it requires, I think, being thoughtful because there are many things that people in the last decade of their life can't do that all of us just take for granted.

35:01I mean, how much do you take it for granted to be able to put your shoes on? Like how easy is it for you to tie up laces on your shoes? Do you know how many people can't do this? How easy is it for you to sit on the floor, play with your kids, just sit with them for 10 minutes and then stand up. You start to do an inventory of these things and you realize, oh my God, there are a lot of things most people aren't able to do in their 80s that if I couldn't, if I took them away from you today, how miserable would you be? And then you want to do the, okay, now fast forward or come to the present and ask, what are things that give you great pleasure today?

35:41And how many of those things do you want to be able to do in the future? and so for me, I love archery. I mean, every day that I'm not traveling, I'm in my backyard shooting a bow and arrow and I don't think I'll be able to shoot a bow the way I do now because today I shoot a bow that's 75 pounds when you pull back on the compound, but I think I could be able to shoot a 40 or 50 pound bow in the final decade of my life. That's much lighter, by the way. It's very nonlinear scale. So 40 to 50 pounds is much lighter than 75 pounds. I love driving race cars and I don't have any reason to believe I'll be as fast in the last decade of my life as I am today.

36:22But if you look at Paul Newman, I mean, he was barely, he was almost driving his fastest at the end of his life. It is possible. So for me, I'd say, look, I'd like to be within 5 % of my driving times today. And by the way, even today, I can tell how physically demanding it is. I get out of a car, I'm exhausted. So I know how much work it's going to take to maintain that level of fitness. Like you, I love being able to play with my kids. And I know, I've done the math, I know that in my last decade of my life, my grandkids will be of the age where I will want to do that stuff with them. so this to me provides the motivation this to me provides the objective the question is now what are the strategy and what are the tactics to make that happen love that thank you thanks for sharing that that's powerful so what are yours then what are the things that you're doing would you mind sharing yeah along with some of your strategy is basically it has to be comprehensive and it has to be built around these four pillars of strength stability aerobic efficiency and anaerobic peak or aerobic peak basically slash anaerobic power.

37:36The reason for it is those are basically the defining features of what allows us to move and what allows us to do so pain-free and what allows us to do so at a high level of performance. So I'm guessing most people kind of understand vaguely what I mean by strength and cardiorespiratory fitness. Stability is a bit of a foreign concept to people. I think I devote an entire chapter to stability in the book. I don't remember what chapter is might be 13, but there is an entire chapter. By the way, the book is 17 chapters. Exercise gets more coverage than anything. I think exercise is three of the 17 chapters, which speaks to my belief that it is the most important of the tools and it has the most potential to both extend life and improve quality of life.

38:24Well, there's a stat you give as well, Peter, that I think is worth sharing of you said exercise has been proven more than any pharmaceutical drug to improve the quality of your life and reduce illness. It's not even close. I mean, just to give you a sense of it, if you took a person who's completely sedentary, this is a person who doesn't lift a finger all day and you can get them to just do light intensity, very modest amounts of activity for 90 minutes a week, you reduce their risk of all cause mortality, death from any cause by almost 15%. That's the tip of the iceberg. I mean, if you actually get people to really boost their fitness, it's about a 50 % reduction in all cause mortality.

39:14There is no intervention we have, pharmacologic or otherwise, that has as much of an impact on the length of your life as having high muscle mass, high strength, high cardiorespiratory fitness. And that's just for your age and sex. So people might hear that and say, oh, what, do I have to be a bodybuilder? No, no, no, no. It doesn't mean that at all. And there are very clear, and in the book I lay these out, very clear criteria by age and by sex for what those metrics look like. But one of the things that I'd consider to be a superpower of yours is your innate curiosity. You started out being a boxer, you do archery, you do motor racing.

39:53Now, what would you advise for anyone that may be thinking about this that maybe is looking at doing aerobic fitness, but wants to explore the right thing for them? Because I think the curiosity of trying different things is something that might be helpful. So, I mean, I think it's important to find something that you will enjoy doing. So I do most of my cardio training these days on a bike. And for me, that's just something that I enjoy. But if a person enjoys walking or running or swimming, that's great. So step one is find something that you enjoy. The second thing is you have to know where you're starting from.

40:32So I assume from your question, we're going to assume we're starting with a person who isn't doing anything right now. So then you have to also keep in mind principle number one of exercise is don't get hurt. So the mistake that a lot of people make is they kind of go out and go too hard. So for a person who hasn't exercised at all, simply walking quickly would constitute a great form of exercise. and the way you can tell if you're exercising hard enough from a cardio perspective at this first level which is called zone two is um if it's difficult to speak while you're doing it but you still can that's the that's the litmus test in the book i talk about the very scientific ways that you can measure that and i use far more precision when i'm defining this for myself but honestly like I think 95 % of people would be just as happy to use the what's called rate of perceived exertion test which is the talk test so if you can be out there talking like this you're not going hard enough yeah if you can't talk except in a few words you're going too hard another benchmark uh a guy by the name of phil maffetone described this as max maximal aerobic fitness he uses a formula for starting this which is estimating it at 180 minus your age is the heart rate to target so for someone like me who's 50 that you would start at about a heart rate of 130 as the estimate and then you would adjust up or down based on the level of exertion before we finish talking about the exercise element i'd like to just return to your centurion decathlon idea i would love to know some of the things that you would love to be doing when you're at that age what you're doing now to make sure you get there but also the level to which you're doing it because i can only assume that if you're no matter how hard you go at this when you're 89 you will not be able to do it to the level that you are now not close you're analogy of, you know, being an archer.

42:39So can you run through some of the exercises, some of the tests, some of the ways you're checking all the time, can I do this right, then I'm going to get to 89 and I'm going to be okay. Yep. So let's start with one of the most important ones, which is just VO2 max. So, you know, VO2 max is a bit of a complicated topic to explain, but it is kind of an important one to understand. And I do explain it in depth in the book. It's a number that represents the maximum amount of oxygen that you can use. It's normalized by your weight. So if we're going to look at the best endurance athletes in the world, they might have a number of 80 to 90 milliliters of oxygen per kilogram per minute.

43:22That's how much oxygen they can use. And that'd be like a Tour de France winner or something. Exactly. So Teddy Pogacar, Jonas Vindegaard, I mean, the best of the best, that's the level they're going to be at. If you look at somebody my age, so someone who's 50, who's in the top 2 % of their age would probably be at a level of 53 or 54 milliliters per kilogram per minute. That number declines as you age, could decline roughly 10 % per decade. Once that number gets to a certain level, you begin to really struggle at doing things. Now, the absolute floor, once that level gets to the high teens, and there are unfortunately going to be people listening to this who might even be there or even know people there, it's hard to walk.

44:21If your VO2 max is 15 milliliters per minute per kilogram, you would not be able to walk four kilometers per hour. You would have a very hard time walking up a flight of stairs. In my view, and I, you know, I have a table in the book that shows all of the different activity levels that you will lose once your fitness level gets below them. For me personally, I never want my level to be below 30 because for the types of activities I want to do, when my VO2 max goes below 30, I will lose the ability to do them. So for example, I always want to be able to walk up four flights of stairs. I always want to be able to walk on an inclined surface.

45:01I always want to be able to carry 20 pounds and walk, you know, things like that. Yeah. Okay. So just as we think of a glider and you have, let's say you're the glider pilot, you see where you want to land that glider. You know, if you're starting here very low, you're not going to make it. The only way to guarantee that you're going to hit that spot is to start high enough because gravity is working whether you like it or not. So if I want my VO2 max to not be below 30 to 32, when I'm in the ninth decade of my life, I've reverse engineered how high it needs to be when I'm 50. So that's how I know what I'm training for today.

45:48that's how I know the level of fitness I need to have today because I've baked it into the calculation of what the decline is and I've done the same calculation for everything for how many seconds I need to be able to dead hang on a bar for how much weight I need to be able to carry what are they at this at your age well I can tell you the standard I hold myself to a slightly higher standard just because I'm an overachiever what should our listeners be yeah so so for example, a male who is between the ages of 40 and 50 should be able to dead hang. So just hang on to a bar and hold themselves for two minutes.

46:26A female should be 90 seconds. Why? That's a great marker of grip strength. Why is that important? Because it's a great indication of upper body strength and it correlates very well with the ability to connect the hands through the elbows into the shoulder and the scapula. You see everything we do in life, every force we transmit to the outside world and we transmit back to ourselves really comes through our hands and feet. So a lot of this stuff has to do with how well you use your hands and feet. Another metric that we have for males between the ages of 40 and 50, they should be able to carry their body weight 50 % in each hand for a minute.

47:11So if someone weighs 90 kilos, they should be able to put 45 kilos in each hand and walk for a minute. And if it's a female, it should be three quarters of their body weight for a minute if they're in that age bracket. And that's, again, that's a great indication of upper body strength, but also of balance and coordination, because when you're carrying that much weight, it's actually not trivial to be able to walk. See, because that was something that jumped out at me that I'd never considered it till I read your book of the grip test and the importance. And even if you relate it to the simplest things of being able to carry the shopping when you're at a certain age.

47:48Yeah, being able to open a jar, being able to hold a handrail when you're walking down a flight of stairs, being able to catch yourself if you slip. So what can we be doing to work on that and make sure that that is? You know, it's funny when people see how strong the correlation is between grip strength and health. And by the way, it's enormous, right? I mean, if you, there's one of the other graphs I have in there shows the relationship between grip strength and the risk of dementia, both death and incidence of dementia. And it's profound. So if you take people with the highest grip strength compared to the lowest grip strength, the people with the highest grip strength have a 70 % lower chance of getting and dying from dementia.

48:31So I would never have related grip strength and dementia in a million years. And on the surface, you'd be right to say, what does that have to do with it? But what it has to do with is grip strength is not about grip strength. It's a proxy for total body strength It's a proxy for muscle mass. It's a proxy for what you had to do to get that grip strength So that's why when somebody says oh grip strength great I'm gonna go buy a little squeezer and just sit at my desk all day and do it. That's not what it means It's what do you have to do to develop such insane grip strength? You've been carrying very heavy things.

49:10You've been lifting very heavy things. Similarly, the association between high VO2 max and low VO2 max is staggering. When you take somebody, and this is for all sexes, ages, like if this is across the board, right? If you say, what is the difference in the risk of death between someone at the top 2 % versus the bottom 25 % for VO2 max, it's 400 % difference in all cause mortality. Meaning at any point in time, the person in the bottom 25 % has a 400 % greater chance of dying of any cause in the following year relative to the person in the top 2%. And again, you might say, why does vo2 max matter that much and the reason is what you need to do to have that much of a vo2 max is what is making the difference yeah does that make sense yes absolutely the vo2 max is the integrator of the signal that produces that benefit if there was one measure then and i hate sort of trying to box you in on these kind of binary questions but if there was one measure that a listener could say, that's going to be my target, that I'm teleological, I want to go after a goal.

50:31What one measure would you advocate would be the target that we should be looking? So by the numbers, the first one would be high VO2 max. So VO2 max by the numbers is the highest predictor of reduced all-cause mortality. The second would be high muscle strength followed shortly by high muscle mass. So all my time spent measuring my waistline. Trivial compared to that. Just trivial compared to that.

51:03Today's podcast is brought to you in association with AG1, my foundational daily nutrition supplement that I take every day to support my whole body health. As always, really pleased that AG1 is partnering with the High Performance Podcast. Look, for the last three or four weeks, I've actually really stepped back from work. I've wound everything down. I wanted to spend time with the kids while they were on school holidays, a bit more time with my wife, having been really busy for the last few months. And what it's actually allowed me to do is really focus on making sure that I get into a routine.

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52:35let's move on to the third pillar if we may of the five can we talk about the importance of sleep Sure. Let's lay it bare for people listening to this. What does a lack of sleep do for us? There's some short-term consequences and there are some long-term consequences. I think in the short term, anybody who's being really honest with themselves can speak to what's happening, right? You're not performing at your best. So, uh, Matthew Walker, I don't know if you guys have had Matthew Walker on the show. So Matthew's written about this stuff quite eloquently. And he's talked about how, you know, even just mild sleep deprivation can be akin to alcohol intoxication.

53:13And there's effectively like, you know, I forget the exact number, call it two consecutive nights of, you know, significant sleep deprivation is akin to driving legally drunk. It's much more difficult to consolidate memories when you're sleep deprived. Your judgment is impaired when you're sleep deprived. deprived, your cravings for garbage food will go up when you are sleep deprived, and you will be more insulin resistant when you are sleep deprived. So of all the things that happen, this is probably the most interesting to me because of the physiologic manner and accuracy with which we can measure this.

53:47Your capacity to dispose of glucose, which is one of the single most important physiologic jobs we have, is to put glucose from our circulation after we eat something into our muscles, your capacity to do that after a week of sleeping four hours a night is reduced by 50%. These are these short-term consequences. And if compounded, lead to the long-term consequences. And the two most long-term consequences that we have insight into are the impact that sleep deprivation has on cardiovascular disease and Alzheimer's disease. It's a less clear relationship to cancer, but I think there's an undeniable link to dementia and to heart disease and how either short sleep, disrupted sleep, fragmented sleep, incomplete sleep, all of these things are causally increasing your risk of those other diseases.

54:43I honestly can see and rack my brain and not work out how and why that would be the case. Well, probably through some different mechanisms. So it's first important to understand what sleep is and what sleep isn't. I think there's a belief that sleep is a passive thing, right? And that sleep is a time to rest the body. But the truth of it is that it's actually not right. Sleep is a very important period of time for the brain to do a lot of repair. And there's a system in the brain called the glymphatic system. And I'm borrowing this analogy actually from Matthew Walker, but the glymphatic system is a system that cleans out the cellular debris that surrounds neurons.

55:27So Matthew describes this kind of like the street sweepers at night that come around and move out the trash. And when your sleep is disrupted or is too short, or you're not getting the right stages of sleep, that system gets impaired. And when that system gets impaired, you have less cellular cleaning of this debris in the brain. And that's leading to an accumulation of these things. Some of them are things such as amyloid beta or tau that are conditions that produce the changes in the neurons that lead to these neurodegenerative changes, including Alzheimer's disease, but also other forms of dementia.

56:09And by the way, I think on the brain front, I think it's also impacted by the metabolic changes as well. So anything that's dysregulating insulin signaling and glucose metabolism is also going to have a negative consequence on the brain. And I suspect that that's also what's happening for cardiovascular disease. There may also be, although I don't think the link here is as clear, there may be a relationship between cortisol levels. So higher cortisol levels when you're not sleeping well, that's been established. And of course, the relationship between high levels and cortisol and cardiovascular disease has been established.

56:41So I think there's probably a causal relationship through hypercortisolemia, as well as through hyperinsulinemia, insulin resistance, metabolic dysfunction, and then this lack of capacity to kind of, if you will, for lack of a better word, clean out the cellular debris around neurons. So to ask you a personal question then, that when you were a medical student, again, I've heard you speak quite powerfully about how there was almost this brutal culture of working ridiculous long hours and then having to make smart decisions that involve life and death for many people doing that on a lack of sleep.

57:18You've almost been a guinea pig in testing some of this stuff out. What does it do to your ability to make better decisions? I mean, I shudder to think about what sort of the horrible experiences I had with so much sleep deprivation. You know, fortunately, I don't think that physicians train under nearly such extreme conditions today. I think 20 years ago in 2003, the rules, at least in the United States, began to change. And I suspect that it's significantly different today. I don't think anybody would go through what we went through, but it is really unfortunate to imagine how many medical errors took place due to basically the arrogance of a system that viewed sleep deprivation as a rite of passage and a badge of honor.

58:07And frankly, a tool that was used to determine your worthiness, right? Like, did you have the, were you tough enough to go for five years sleeping rarely more than a few hours a night? I still think that pervades lots of our culture today. The idea of going without sleep is a sign of passion. It's that hustle culture. Yeah, it's interesting. I mean, you guys would know this better than I do. I'm guessing that there are probably still some corners of the world where that's true. Do you still see that with high performers? Because I would think that by this point in 2023, most high performers really understand that that's a detriment.

58:55And by the way, I don't just mean athletic performers, I mean, anyone who's trying to be top of their game, I would think at this point in time, isn't playing that game anymore. In my, and this is only anecdotal, I'd probably say those that have got to high performance have had to learn the lesson so they would understand it. I think those that maybe aspire to high performance need to still learn it. Interesting. What should we be aiming for and how do we get it? How do we get people to a point where sleep is doing for them the things it needs to do? I mean, the first thing you have to do is you have to realize you can't force sleep.

59:33You can't just snap your fingers and make sleep happen. You have to prepare to sleep and you have to give yourself the right amount of time. So you really do need to give yourself about eight hours to make this thing happen. So meaning you got to really plan to have eight hours to be in bed. Eight hours in bed. Yeah. And of that, you might sleep seven hours, 7.50, 7.30. So right out of the gate, the first mistake people are going to make is they're not going to give themselves enough time to sleep. If you're only going to give yourself six and a half hours to sleep, you already made a mistake.

1:00:00So time is the first component to this. The second thing I think is you will make your life infinitely better if you can be quite consistent in when that eight hours occurs and make it occur the same time every time, weekends included. So one of the big problems that young people have is something called social jet lag where, you know, they have jobs. So they have to get up early in the during the week, but on the weekends they want to sleep in. And so they're dramatically changing their circadian rhythm between weekday and weekend. And this is actually one of the advantages I think we have as parents is we get up at six every single day because our boys get up at six every single day, no matter what.

1:00:43Another thing that's very important is what is the room? What is the experience like? Is it cold? Is it dark? Is it otherwise unstimulating? Right? All of this matters. You'd be amazed at how much distraction people can have in their bedrooms, how much light there can still be in the bedroom, how much they're doing in the bedroom that's not sleeping. you know and I get it sometimes you live in a you know you live in a city like London or you live in a city like New York where you have to also have your office in your room and so you associate many things with being in the bedroom that go beyond sleeping yeah but in an ideal world you really just want to kind of keep that room dark keep that room cold and keep that room conducive to sleep a very important thing is how do you prepare to sleep so let's just say right up until this point, a person's like, I'm with you, Peter.

1:01:30I got it, man. I'm going to be 11 to seven every day. I've got it dialed. Okay. If you do all of that stuff, great. But if you're on your phone checking social media until 10 59, and then you hop in bed and just check one more thing and then put the phone next to you, you haven't prepared yourself to sleep. So you have a restless racing mind as you try to go to sleep. That's just not going to make much of a difference. And by the way, A lot of people, I think, used to make a ton of hay about how you shouldn't be looking at any light or electronic surface before bed. But it turns out that phones are disproportionately bad.

1:02:10And in fact, they seem almost consistently worse than than than say TVs. And you can't make the argument that the light is that much different. It's probably much more the nature of what you're doing. You know, if you sit down to watch a movie on TV, that can, I'm not suggesting that that's necessarily a good sleep hygiene practice, but it's probably far less negative than, you know, checking email from work. Well, I think you're detached from your life, right? Yeah. You watch a film, you're detaching yourself from reality. What do we mainly have on our phones, our work email, our social media accounts, and the news, which is directly in your life.

1:02:50So you can understand that. Yeah, yeah. Yeah. So those would be kind of like what I call kind of like the big bases of sleep hygiene. So what's your routine in the evening? It's everything I just said. I mean, in addition to that, I really like to sauna and cold plunge before bed as well. Yeah. Yeah. So getting my body temperature up, cooling it down, and kind of getting into bed. It's pretty boring, actually. Phone in the bedroom? No. And also, I don't even use my work phone in like the two hours before bed. Well, that leads us into the other area that you touched on in the introduction, Peter, which is around how do you detach work from home?

1:03:31and for like you say for a lot of people maybe the bedroom is also doubles up as the office if we're living in a flat in a big city so it probably leads us to that next question which is what lessons and tips and hints have you learned about being able to create that clear demarcation i would say this is my hardest area so i mean i think you know most people would look at me and say wow that guy really he he's got his exercise routine down to a science and and he eats pretty well and sleeps well. And I think those things are true. I would say the thing that I struggle with the most by far is working more than, than I should.

1:04:08And I think that I just have to be constantly at war with myself over this and constantly setting boundaries. And, you know, for example, like having two phones has been a very big help. This was something I just figured out a year ago, maybe less, which was, oh my God, if I just got that second phone, I could still have a phone with me if I want to be able to take pictures, if I'm out with my kids, if I'm, you know, like, unfortunately, like now half the electronics in the house, I'll work off the phone. You know, there's like an app for that. So I could still have that, but not have the phone.

1:04:43Right. So that, that became a very powerful tool. What did that do for you? Oh, it was so fantastic. It made such a difference. That was a huge, again it might sound silly like why would you buy another phone to not have it be a phone but what it did for me was allow me to go to bed without thinking about work or seeing a text message that would annoy me or upset me or seeing an email that would chirp me or anything like that like it was just not doing that purely for like it was a hundred percent decision i made for just mental health right but it's not a phone that you use to connect with the outside world you what do you use that phone for then?

1:05:17Your non email phone? Like what do you? Nothing. I use it to have, to have a camera. It has my calendar. So if I'm out and I need to know how to get somewhere, you know, that's it. I have music on it. So I take that. That's the phone. If I'm out like today at the gym, that's the phone I had with me. Can we talk while we're on the subject about distress tolerance? Would you explain that to our audience? Yeah. It's an idea that basically, as its name suggests is how much are, are we at any point in time able to buffer ourselves against adversity, against emotional distress. Which is, you know, having two phones is a way of doing that.

1:05:52Correct. Yeah. So basically half of what I'm trying to do in life is figure out a way to buffer myself against the distress that the other half of my life creates. It's a bit unwise. But I spend my life going, hey, deal with distress, high performances, pushing through challenge. You know, it's a bit like taking a vaccine. You need a little bit of this to insulate you from being derailed by it, if that makes sense. So how do we get the balance right between having resilience and tolerance and being able to cope with sometimes life shit? Yeah. Well, I think it's different for everybody, but in the final analysis, it just comes down to how are you doing, right?

1:06:34I mean, from a hormetic standpoint, we need stress. I think a stress-free life, a life with no stress, would be relatively unfulfilling and quite boring. So, you know, if I were purely optimizing to have no stress in my life, I wouldn't be doing what I'm doing. I would choose another path. And so most of us have chosen the path we've chosen, presumably not to minimize distress. But nevertheless, distress comes into our life. So we're not we're neither trying to maximize nor minimize distress. We're trying to optimize around something else. And distress happens to be the collateral that comes with it.

1:07:07And so the question is, are you under more distress than you're capable of handling? And I think you know the answer to that question based on how the rest of your life is going. I mean, if you can't sleep because of too much distress and you attribute that, for example, to, well, I can't seem to get my phone off my mind, then maybe what we just described becomes a great trick for reducing distress. What were the other ones that you identified for yourself or how do we go about identifying? Well, I mean, I think, you know, exercise is a very important part of distress tolerance for me. So there's a really important physiologic component of what exercise does from a hormonal standpoint that I think for almost any human being will increase distress tolerance.

1:07:58basically anything that you can do to improve your physical health so sleeping better eating better exercising better all of those things are improving it on the sort of less obvious things for me personally and i think there's reasonable data on this i think cold exposure is quite beneficial it stimulates the parasympathetic nervous system which is uh part of the automatic or autonomic nervous system that is responsible for more of the rest and digest function So when you activate the parasympathetic system and the vagus nerve, which is just one of these big nerves that runs through your chest, when you activate that system, you're kind of lowering the amount of fight or flight activity that you feel.

1:08:40Back home, I do this by sitting in a cold plunge for five or six minutes a day. For some people, meditation becomes a fantastic tool by which they can sort of build up distress tolerance. And I think the way for people who haven't meditated to think about that is at least one form of meditation really has you fixating on an object of meditation. Usually the breath is the most common one. And the purpose of that exercise is not to stop thinking, but rather to notice your thoughts. And even a person who does this for a relatively short period of time, you don't need to be sort of an expert, quote unquote, meditator.

1:09:19But a person who meditates for even a couple of months kind of gets into the hang of realizing that we have a constant barrage of thoughts that are just never leaving us. And if you can notice that, you can begin to notice that some of the distress you're experiencing is nothing more than the thought that you're allowing to sort of fester and permeate. And by instead of trying to not have the thought by simply observing the thought, a lot of times that thought dissipates and the distress goes away. Journaling for me and psychotherapy, working with a therapist, hugely important parts of increasing distress tolerance.

1:10:00And does all of this get you closer to the centurion decathlon? Because there's part of me that thinks, well, people's relationship with stress and anxiety and pressure from the outside world, we see it as a period in our lives that we kind of have to accept because we're in that busy life period. But it will go when we're in our 70s or our mid 60s when we retire. So then I'll be okay. Is there a carryover effect from this period? That's a great question. I would bet that there are some people who were just incredibly hard charging in their thirties, forties, fifties, sixties. And somehow when they retired, it was all fine and dandy.

1:10:43But if I had to bet, I would, I would guess that that's a rare minority. I would think that for the majority of people, the seeds that you sow in your youth are the same flowers that come to harvest later on. One of the things I think about a lot is how will I look back at now, at this moment in the future? What will I tell myself? And almost invariably it's do less. Yeah. It's not push harder. So I have to kind of remind myself of that, which is the guy in his last decade looking at you now will say, you're not spending quite enough time with your kids. And even when you're with them, and even if you're with them, not looking at your phone, your mind is somewhere else, right?

1:11:32Why, why is that? And I feel lucky that I have three kids so I can already see the difference between a teenager and a young kid. And I can realize how quickly things change. And I feel very fortunate that kids are a wonderful way to anchor to the aging process. So I know that kids are not for everyone, but I'm really glad that they're for me. When, again, I was reading your book, Peter, so this is me projecting on you, and I might be wrong on this, but I saw that you were pretty competitive in terms of the sports you did. You were an overachiever, you know, in terms of defying what you should have done where people never expected you to go to medical school, but you were also a perfectionist.

1:12:17and this comes into that area about immunizing ourselves against emotional distress there are things that I could identify with and I'm sure lots of listeners might often the battle for this is what goes on internally rather than the external world I'm interested in what kind of steps or advice or techniques you've learned to be able to live with those impulses and harness them for the good rather than the destructive I mean, I don't think I could have done it without the, the, the very intensive therapy that I talk about in the book where I actually had to go away because what I had to sort of come to grips with was understanding what was the underlying driver of that.

1:13:03Like what was that behavior a response to or an adaptation to maybe is the best way to frame it. And I think only when I came to understood that could I then be in an equilibrium with those forces. And I think that's really the right way to describe it for me, because I'll never be in the point where those forces won't be a part of my life. I'll never be the guy who doesn't want to work. You know, I'll never be the guy who doesn't care what the product looks like. I'll never be able to completely shed the the workaholism the perfectionism I simply can't but I could be in a much healthier equilibrium with them but only because I've gone through this very intensive understanding of what was at the root of them how did they shape me and now the other thing is I have more people that help me right meaning I have an accountability stream around me.

1:14:02I mean, starting with my wife, right? My wife is my most important accountability partner. I mean, even on this trip, she's been kind of busting my balls a little bit. She's like, you're freaking working a lot. And I was like, I know, I know, I'm sorry. And, and like, you know, the other day we found out like we have to, you know, dress a certain way at Goodwood. And it's like, I didn't bring any nice clothes. So I had to go shopping to look for clothes. And I was kind of irritated doing it. And she's sort of like, you know, you're letting this get in the way. Like this is a fun time. And she, and she was right.

1:14:31So anyway, But my point is like having somebody who can remind me of that is something that I now welcome. Whereas in the past, I would have been very annoyed at that. I would be very annoyed if someone was busting my balls. So for a listener that maybe doesn't have the opportunity or the access to the kind of therapy that you went through, though, what would you advise would be the kind of questions they should be asking themselves in terms of for their better emotional stability? It's a very good question. And I have to be honest with you. I don't really know. I don't have as great a checklist here as I think I have for all the other metrics.

1:15:11I can tell you exactly what metrics to look for on your strength, on your stability, on your fitness, on your sleep, on your nutrition, all of those things. I think it's just a general sense of what are your relationships like? I think that's probably the best barometer of your emotional health. Do you have people in your life that you can call up and talk about something that is deeply troubling and upsetting? Are there people who can call you in that way and can you be there for them? How do you handle the ebbs and flows of your mood? I mean, I think there's this misunderstanding that being emotionally healthy means you're always happy.

1:15:54I don't think that's remotely true. You know, happiness as a sort of fleeting transient state and sort of being emotionally healthy are quite different. An emotionally healthy person can be quite unhappy at times, but they're not destructive when they're unhappy to themselves and to others. An emotionally unhealthy person will make a mistake and they'll double down on the mistake and they won't reconcile the mistake. Whereas if you're emotionally healthy, you'll make a mistake, but you'll work to rectify it. You'll fix it. So I think probably the most important thing is just kind of taking stock of those things.

1:16:34The truth of it is, I do think that this is an area where I think there are more and more resources that are going towards getting therapy. And I do think it's very important that people understand that a lot of our experiences when we grew up, good and bad, really had a significant effect on shaping who we are as adults. And many of us as adults are just big children. Like we shouldn't confuse the size of our bodies with the maturity of our insides. And I think I was a classic example of that, right? I mean, I was an adult physically, but emotionally a total child. And I had to go back and understand my childhood to then separate the child from the adult.

1:17:23can we just give a shout out to your wife here as well because i think she's the hidden hero of your book she sure is yeah because there's that brilliant story that made me laugh out loud where you describe you've done this great swim i think is it in hawaii where you are at the time might have been catalina which is off the coast of los angeles yeah yeah you've done the swim and she gives you some feedback in the most elegant and sensitive way possible would you tell us about that because i think there's something in it about sometimes it's not what you say it's how you say it that really lands the message that's such a british thing to say too isn't it right just yes so so understated uh no she just she she wanted to tell me that i was getting a little overweight but she said it in the nicest way possible which is i think you should work on being a little less not thin very good she sounds like a special woman she is uh before we move to our quick fire questions we have a final pillar that we want to talk to you about which is the idea of supplements and additional um input into the body and there will be people listening to this who think you get it all from food if you eat right you will have everything you need there'll be others that are on 60 tablets a day and don't really have any idea whether they're working or not i mean so i would love to hear you talk to our audience about the power of supplementation well i mean uh the truth of it is i don't know that we'll ever fully know the answer on some of these things because there's not as significant a motivation to study them the way at least there is a forced regulatory manner in which we have to do the same for pharmacologic drugs, right?

1:19:01So we can at least have some sense of what the risks are and what the benefits are of a certain class of drug. And we might have a, you know, we might be able to look at an antibiotic and say, well, you know, look, the antibiotics clearly all come with risks and dangers, but they also come with these benefits. And so if you look like this and you have this infection, odds are you really do want to be on this drug because of this reason. And that's obviously a drug that you take for a short period of time. We can do the same calculation for drugs that you take for long periods of time. When it comes to supplements, those studies don't exist.

1:19:35So even taking something as simple as vitamin D. Now, I believe that vitamin D is an important hormone, and I believe that most people these days are probably deficient in vitamin D on account of the fact that we don't spend enough time outside. And again, that's just a consequence of modernity. That's a consequence of, in many ways, the benefits of the world we live in today. And so the question then becomes, well, should we supplement with vitamin D? And if you turn to the literature to answer that question, you'll get a very unsatisfactory answer, which is probably not. But if you really scrutinize those studies, you come away realizing they've failed to ask the question correctly, right?

1:20:17They've, I mean, I can give you an example of a very prominent study that looked at this, which took a group of people who had low levels of vitamin D measured. So I think these people were below a level of 30 and they gave them all 2000 IU of vitamin D and they never really checked who took it and who didn't, and they never measured their levels again. And then they concluded in, I don't know, five, seven years later, it didn't have any positive benefits on their health. The problem with that is many fold. First of all, you don't really think of vitamin D as something that's a fixed dose. You think of it as a target level.

1:20:51So a better way to do that study would have said, let's take people below 30 and give half of them a placebo. And let's give the other half whatever amount is needed to get them to say 60, which would be a significant enough difference comparing people at 30 to 30 at 60. You might also want to study them for a longer period of time, but understanding that that might be challenging. And then you might have a better sense. So I would be more confident saying yes or no to vitamin D if I had those type of data. But absent those type of data, I kind of err on the side of thinking that having a vitamin D level somewhere between 40 to 60 or 70 is probably right.

1:21:28And therefore I supplement to make sure that I'm in that level. And the amount of vitamin D I need to get there is about 5 ,000 IU. What should our relationship be with supplements? I mean, again, I think it's the most complicated thing I talk about with my patients. And I have a series of questions that I ask them with respect to every supplement. So if I have patients that show up in the practice taking, I mean, literally some people show up, as you said, taking 60 different things and they can't tell me why, and they can't answer the most fundamental question. So I will start by asking them the following question.

1:22:03Are you taking this supplement because you believe it is impacting your lifespan or your healthspan? If it is impacting your lifespan, do you believe it is doing so through a specific disease modulating pathway or through some broader gyroprotective pathway? A geoprotective just means targeting a biologic hallmark of aging rather than a specific disease like cancer or heart disease. Are there data that demonstrate the safety of this product in humans? Are there data that demonstrate the efficacy of this product in humans? If not, how compelling or robust are the data in non-humans? Like I just literally, it's like eight questions or something like that.

1:22:51And I think by the time most people get through answering these questions for three of the 60 supplements, they realize, okay, how about we put all the supplements away and we come back to it through the lens of need? So I think a more important way to think about this is what's the gap you're filling? So if you can demonstrate vitamin D is not at the right level, it makes sense to supplement. If you can demonstrate EPA and DHA are not at the right level, it makes sense to supplement those. If you can demonstrate homocysteine is too high, B vitamin level too low, then it makes sense to supplement.

1:23:23So I'm not opposed to supplementation. I just think it has to be very targeted and very thoughtful. And if I can't answer those questions that I laid out, then I don't, it doesn't make sense. Yeah. I mean, most people wouldn't go through having blood tests and getting themselves looked at right to work out what supplements to take. So is there, is there anything that you think we should all, is there like a blanket approach that we should all be taking here, take these things because it's a good insurance policy or is it not that simple? I think it's hard with supplements. Yeah. Yeah. Are you ready for some quick fire questions?

1:23:56I'm a little nervous. There's no need to be nervous. What are the three non-negotiables that you and the people around you need to buy into? Daily exercise, almost without exception, being outdoors at some point during the day without electronics. So for me, like walking outside with a heavy backpack, something called rucking, something of that nature, but just being outside and being able to observe nature and probably getting an appropriate amount of protein per day. These are all health related. Yeah. Yeah. They're great. What advice would you give to a teenage Peter? I'm sad to say he wouldn't listen to anything I would say.

1:24:42Um, but I guess I would give it to him anyway. And I would encourage him to do at least in his twenties, what he waited until his forties to do with respect to understanding the forces that are shaping him. If you go back to one moment in your life, what would it be and why? Boy, I can answer this two ways. There's a positive and a negative way. Um, Why don't you give us both? I think the positive is I would probably go back to the day my daughter was born again. I think as much as I remember it now, I mean, it was, I think, still one of the most remarkable things ever. So I think to be able to go back and experience that again would be amazing.

1:25:21I think there's a moment in my life when I did something that was incredibly hurtful to someone who meant a lot to me, and I wish I could go back and undo it, even though that person has forgiven me for it. What's the most valuable piece of advice you've ever received? I don't know that it's advice, but it's a profound statement that has helped me understand how I feel, and it's that 90 % of male rage is helplessness, which allows me in moments of rage to understand why I'm so angry. Would you please recommend one book or maybe a podcast or a TV series that you would like our audience to take a look at?

1:26:07Maybe The Comfort Crisis by Michael Easter would be a great one for people to read if they need a little bit of motivation to get moving again and to sort of break out of their comfort bubble. And the final question then, What's your one golden rule to live a high performance life? I mean, I think you can never take your eye off the prize. And the prize is, is my eulogy going to be better than my resume? If you think about that, I think you're going to generally make the right decision day in and day out. What a brilliant way to end. Peter, thank you so much for your time.

1:26:58Damien, Jake, there's loads of us to pick out from that. I think the key is you can just ignore that and think loads of great information and carry on exactly as we are today. Or we can actually just stop and go, right, what is my relationship like with my phone? What is my relationship like with sleep? Can I carry out some of those things he talks about, like hanging from a bar? And should I be setting my own metrics and my own parameters for doing exercise? because it's all great information but it's only great information if you act upon it yeah definitely i think what he was a great advocate there is that famous stephen covey quote that you should always start with the end in mind and i think we're going to be so wherever we are at the moment we can start but if we do that projection forward and think about what do i want my later years to be like do i want to be able to go walking do i want to play with my grandchildren do i want to be able to go on holiday and enjoy the experience if we start with that in the mind that then forces us into looking at what we're doing today can we hang from bars can we are we making smart choices when we go food shopping it's also a reminder as well that you don't stumble into this stuff like it takes a bit of time and a bit of preparation and a bit of thought you know before the interview we sat outside and he genuinely did eat some nuts out of a pot that he brought with him and he had four or five like jerky sticks um venison actually that he ate and that was his lunch so it means that we offered him a sandwich and we offered him some brownies and some fruit and some other bits and pieces but the prep the thought the process was already there we have to start doing that you can't just stumble through get to 70 and think shit i've just been diagnosed with something horrible i wish i thought a bit more about my small daily decisions those world-class basics we talk about i see it in so many different aspects of lives i don't know about you like when you meet people that have maybe been successful financially but they've still got that voracious appetite for more and that metaphor that peter used of don't go food shopping when you're hungry yeah is really important that i think when i've met people that have maybe made a lot of money but need more it's because they never set themselves a target of how much is enough for you what's the quality of life you want around it and i think that metaphor extends whether it's like you say to exercise well what do you want what are your targets whether it's your nutrition what is a healthy diet for you very important thanks mate thanks mate and that brings us to the end of today's episode of the high performance podcast don't forget you can watch these episodes on youtube you can also download the all new high performance app which gets you closer to your own version of high performance and you know peter spoke about doing those little things every day which are good for you and the high performance app offers you daily boosts, daily short clips of inspiration just to uplift you, to guide you, to help you get closer to high performance.

1:29:47All you need to do is click the link in the description to this podcast or head to the App Store to download the all new High Performance app. Peter, thank you so much for joining us. Thank you so much for listening and we'll see you very soon for more from the High Performance Podcast.

1:30:10Thank you.