#385 - AMA #82: Applying the tools of longevity in the real world: disease prevention, DEXA scans, artificial sweeteners, injury recovery, stability training, habit formation, protein intake and mTOR activation, and more

0:10Peter Attia:Hey everyone, welcome to a sneak peek, ask me anything or AMA episode of the drive podcast. I'm your host, Peter Attia. At the end of this short episode, I'll explain how you can access the AMA episodes in full, along with a ton of other membership benefits we've created, Or you can learn more now by going to peteratiyamd.com forward slash subscribe. So without further delay, here's today's sneak peek of the Ask Me Anything episode.

0:38Peter Attia:Welcome to Ask Me Anything AMA episode 82. In today's AMA, I answer listener questions across a wide range of topics. Less about deep dives and more about how I think through real world trade-offs and apply the science and practice. So what are we talking about here today? We can talk about how health priorities and strategies should shift across different decades of life, which chronic diseases feel toughest to manage, and how I think about that hierarchy of risk, which emerging interventions look most promising beyond exercise, wearables, which consumer metrics are actually useful in practice, DEXA scans, what optimal screening intervals look like and how to interpret the results over time, behavior change, what patients struggle with most in health routines and how to help changes stick, training for balance, stability, and injury resilience and lessons from some training setbacks, high protein diets and mTOR, how to think about mechanisms versus outcomes, diet sodas and non-nutritive sweeteners, how to evaluate them and frankly what to compare them to, plus a grab bag of some additional listener questions including health fads, emotional health and sleep routines.

1:46Peter Attia:So without further delay, I hope you enjoy AMA number 82.

1:56Peter, welcome to another AMA. For today's AMA, our goal is to hit a variety of topics and questions that have come through frequently, most commonly. And instead of doing deep dives on some of these topics. What we're going to do is more talk about them, how you would speak with patients about them if they ask these questions, or their questions on how you work with your patients on specific issues. So goal here is to be much less in-depth and much more practical and actionable. And with this, we'll cover a variety of topics, including how priorities around health shift as people age the best tools we have to prevent dementia what wearable data do you think is actually useful for your work with patients how you work with patients to make lasting changes in their health routine how to think about training for stability recovering from injuries question on diet soda mtor as it relates to high protein diets and more so with that said i think we'll just jump right into it.

3:01First question being, as someone thinks about their trajectory as age, so if someone goes from their 20s to 40s to 60s and beyond, how do you work with patients around how their health priorities, strategies, tactics should shift across those decades as they age?

3:20Peter Attia:Well, I mean, I think it's a great question. And I get asked this in various forms all the time. But also I think in the spirit of full disclosure, I don't work with 20-year-olds typically. And therefore, I don't think I have the breadth of experience to really speak intelligently at that age range the way I do for people in their 40s and above. Because I would bet that the median age of my patient is in the mid-50s with an interquartile range of call it 40 to 70. So I think broadly what I would say is that you can get away with so much in your 20s. And again, I don't know that much of our audience even skews that young.

4:05Peter Attia:But anybody listening to this who's in their 20s or certainly anybody who can remember being in their 20s and even I can knows that what you can get away with is just incredible. And so one of the things that I talk about with my daughter, for example, who's a teenager is, look, this is the period of time in which you can overtrain. you can expand the envelope of your capacity. I know that the reason to this day, despite the fact that I don't train that hard, I still have a much higher VO2 max than would be predicted, I think, by my training volume. I owe that all to what I was doing when I was young.

4:39Peter Attia:That's one example. But I think we can achieve a lot by pushing in our 20s. So I actually would encourage people in their teens and 20s to kind of find their limits a little bit. Again, you're not going to pay the same price that you will in your 50s or 60s in doing so. Now, obviously, that means you still have to be reasonable and don't do things that would cause injuries. But again, I think that's a period of time for exploration and growth. I think when people get into their 40s, most people start to have that first brush with mortality. And part of that is external. You might be watching your parents' age or things of that nature.

5:15Peter Attia:But I think also part of it is internal. And even though it's not your own mortality that is readily apparent, it is apparent that you are not the person you were before. Probably, and I would say certainly by the late 40s, that becomes true. And again, this manifests itself in many ways, right? So for example, patients will say, look, man, there was a day when I could throw down three drinks a night and feel nothing. And now I just have a headache the next day, or I don't sleep well, and I don't perform well the next day, and all of those other things. And so I think that that's an insight into what's happening to us physiologically in our 40s and 50s, which says we really need to start being very deliberate about what we do physically and how we think about ourselves in terms of disease management and training.

6:00Peter Attia:Again, when you look at a disease like atherosclerosis, rarely, rarely is it going to brush up against somebody in their 40s. You can count the number of cases you see where a person has an MI in their 40s. But it is undeniable that most people, at least microscopically, if they're walking around with high risk factors, don't have a burden of disease. And so really, I would say that by the time you're in your 40s, you really need to be thinking about what am I doing from a prevention standpoint? I don't want to wait too much longer to start taking those steps. And that means, again, looking after the fundamentals and the basics.

6:36Peter Attia:So am I metabolically healthy? Because for many people, this is when they start to go off the rails. Am I still faced with dyslipidemia or is hypertension starting to creep up? All of those other things. And of course, I always like to bring it back to physical and exercise. This is really a time where you don't want to start missing workouts. And I know that for some people it's hard to do, but you're better off doing something very frequently and not getting out of the habit than you are taking long periods of time off and then coming back and trying to be heroic. Now, I think once you get into your 60s and beyond, the name of the game is maintenance if you've done a good job until that point.

7:15Peter Attia:But the good news is if you haven't, there's still an enormous opportunity for growth. I think that's an important distinction. So if you've come into the seventh and eighth decade of your life not particularly healthy, that should not be viewed as a scenario by which you decide, well, the die's been cast and away I go. Rather, it would be, no, look, I can still make gains here. We've seen patients that come into our practice in their 60s with a VO2 max in the high teens, low 20s. That doesn't prevent us from training them and getting them to a much higher level of fitness within two or three years.

7:48Peter Attia:The same is true with resistance training and things like that. And of course, it's never too late to start taking the preventive steps around chronic disease. Alternatively, when a person comes into their 60s and 70s in great shape, our goal is do no harm, right? It's how do we preserve this for as long as possible? And that might mean being a little bit more deliberate in some of the training that we do, maybe trimming a little bit of the work that they do off and adding different types of work to it. But I would say broadly speaking, that would be my approach. Jumping off that, the next question we got touches on the kind of major chronic diseases or as you call them, the four horsemen.

8:25Do you want to just run people through real quick what those four are before we get to the question?

8:31Peter Attia:Yeah, they're sort of the big four killers in chronic disease land. So atherosclerotic cardiovascular and cerebrovascular disease being one, cancer, all of the neurodegenerative diseases and dementing diseases is the third. And then the foundation upon which these all lie is metabolic disease, which is a broad term that encompasses everything from insulin resistance through fatty liver disease up until type 2 diabetes. And the question which obviously is going to be a little hard to answer in general, right? Because I know it can vary from person to person, but it was an interesting question around of those major chronic diseases, which do you find the toughest to combat or which do you worry about the most when working with your patients?

9:17Peter Attia:Well, I'll start with the opposite question, Nick, which is, which do I worry about the least? And I worry the least about metabolic disease and cardiovascular and cerebrovascular disease because, one, we have a pretty good handle on the drivers of those diseases. In fact, we have an exceptional handle on the driver of those diseases. And that's half of the equation. The other half of the equation is in response to that, we also have incredible tools for how to combat them. So when it comes to reducing the risk of diabetes and cardiovascular disease or even treating them when present, we know what to do.

9:49Peter Attia:We've got the tools. So now let's really focus on the other two. Now, the other two are kind of interesting and so we'll take them one at a time. In the case of cancer, you're dealing with a disease that has two very clear and well understood what we would call environmental triggers or behavioral risk factors. The first is smoking and the second is obesity. Although, as I've said many times before, obesity is simply a proxy, in my view, for the constellation of things that accompanies insulin resistance. So there's a high overlap, of course, between those. But really, I think it's the hyperinsulinemia and the inflammation that often, though not always, accompanies obesity that is driving risk there.

10:27So obviously, when it comes

10:29Peter Attia:to cancer, step one is mitigate those two things, right? Don't smoke and be as metabolically healthy as possible. But as anybody listening to this knows, just because you've done those two things, does not for a moment guarantee you're not going to be diagnosed with cancer. And I think that's in many ways what makes cancer a very frightening disease, is that as far as I can tell, at least 50 % of cases of cancer arise in individuals for which there is no observable risk factor. And as Bert Vogelstein put it many years ago in a then very controversial paper that I believe was in Science, it's simply about bad luck.

11:07Peter Attia:and that genes are constantly undergoing mutation. DNA is constantly undergoing mutation. Most of the time it is being repaired. If it is not being repaired, most of the time the cells that undergo those non-repaired DNA mutations are being weeded out. But every once in a while, a population, a clonal population of these will emerge and will evade the immune system and will ultimately become a cancer. And again, I think that's happening about 50 % of the time, which again turns our attention then to screening. This is why screening is so important because it's sort of like playing Russian roulette with three rounds in the chamber.

11:47Peter Attia:So I would argue that that's pretty scary to me, Nick, when it comes to my health and the health of my family and the health of my patients and friends and anybody that I care about. On the neurodegenerative side, I kind of divide these into two categories, frankly. On the dementia side, we can really stratify a lot based on genes. And so a person's genes will play a pretty significant role in risk. And obviously the APOE4 gene is the most obvious of these. But unfortunately, there are other genes that are involved here that are fortunately rare, but unfortunately highly, highly penetrant and highly unmodifiable in the way that APOE4 is modifiable.

12:28Peter Attia:So across that spectrum, of course, my concern increases as the genetic risk increases. The good news is I feel we have a lot to offer patients there in terms of prevention today that we didn't have five years ago and 10 years ago in terms of our understanding. So interestingly, I find myself slightly less concerned about this than I was concerned five and 10 years ago. Now on some of the neurodegenerative diseases outside of the dementing diseases, I find these to be also terrifying. So here I'm thinking about diseases like Parkinson's disease or Lou Gehrig's disease, Huntington's disease, of course, which is a genetic condition that arises from a very clear genetic mutation.

13:11Peter Attia:And here I find these, I take some comfort in knowing that at least in the case of ALS, the prevalence of these are quite low. But again, we still have no earthly clue what's driving them. Yes, there are probably some cases that arise from genetic risk. But the truth of the matter is we just don't really know. Again, with Parkinson's disease, we certainly are familiar with some of the genetic things that are driving risk, but that doesn't answer all of it. And therefore I have concern about those. But I also realize that we have certain things under our control. And just as cognitive reserve allows us to maintain resilience against cognitive decline, so too does movement reserve give us some manner in which we can protect ourselves or at least be resilient towards the neurodegenerative diseases that tackle movement.

13:59And just to double click on a few things on the cardiovascular disease and metabolic diseases, just because you kind of, how you answered this question was which ones are the toughest to combat, most worry about, just because those diseases are easier to combat, that doesn't necessarily mean that people should ignore those because they're still number one killer in cardiovascular disease. And metabolic disease hugely drives everything else, correct?

14:29Peter Attia:Absolutely. Yeah. I mean, if we did nothing else on this podcast but talk about cardiovascular disease and all of the ways that we should be screening for it and preventing it, we would probably save more lives than talking about anything else. And so, yeah, I am still heartbroken when I learn of the death of anybody due to cardiovascular disease, including actually a a mentor of mine who died suddenly, somewhat recently, and insanely healthy individual who just dropped out of a sudden MI at about the age of 70. This is a guy who functioned like he was about 52 and then just dropped dead suddenly.

15:05Peter Attia:And yeah, I'll always kick myself for not being more of a hardliner about forcing him to do some of the screening stuff that I think would have made a difference. And we'll link in the show notes to various content, podcasts, AMAs, newsletters, et cetera, on cardiovascular disease. The second one to follow up on, which is a question we got, which fits really well with what you just talked about is for dementia prevention, besides exercise, which you've openly talked about as one of the best ways to reduce the risk of that, what looks most promising to you. Thank you for listening to today's sneak peek AMA episode of The Drive.

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