The Megyn Kelly Show - Importance of Exercise, Effects of Alcohol, and the Science of Longevity, with Peter Attia

00:00:00.540 Welcome to The Megyn Kelly Show, your home for open, honest, and provocative conversations.

00:00:12.100 Hey everyone, I'm Megyn Kelly. Welcome to The Megyn Kelly Show. Do you have a goal of living well,

00:00:17.900 and I mean living well, into your 90s or even 100s? It's possible. And you already have the

00:00:25.060 tools to make it happen right at your disposal. Mm-hmm. Dr. Peter Otia is a physician who focuses

00:00:31.840 on the applied science of longevity. He is with us today to explain how it's possible to increase

00:00:38.480 your lifespan while simultaneously improving your quality of life. And his life is fascinating as

00:00:47.380 well. Peter, so good to have you here. Hey, yeah, great to be here. Thank you. Yeah, the pleasure's

00:00:52.040 all mine. I'm looking forward to this greatly. So let's just start a little bit with your personal

00:00:55.480 story so people know the very weird, fun, interesting journey you took toward this place you're in,

00:01:02.820 which is not only a medical degree from Stanford, a residency at Hopkins, a fellowship with the

00:01:09.920 National Cancer Institute, but now your own fasting app, your own successful podcast,

00:01:16.960 the Peter Atiyah Drive podcast, and a whole sort of wellness program that takes a look at this

00:01:23.580 thing, longevity, which we'll get to. So let me just take you back. I don't want to go too far,

00:01:27.260 but you're Canadian by birth, and you were raised there. And you, as my parents told me,

00:01:34.720 didn't seem like anything so special when you were basically K through 11th grade.

00:01:39.600 Yeah, that's funny that you know that. Yeah, I was not a particularly happy student,

00:01:45.680 didn't, didn't like school very much at all from about the fourth grade on. And, uh, you know,

00:01:52.500 my passion was boxing. So I, I wanted to be a professional boxer and that was kind of the only

00:01:57.780 thing that mattered to me growing up. And so you're, if I were to talk to your

00:02:02.320 like eighth grade teachers about little Peter at that point, what would they say about you?

00:02:08.600 Uh, well, I could quote one of them who said, Peter Atiyah, you are the biggest loser in this

00:02:14.100 school. So, uh, that, that pretty much sums up what they thought of me.

00:02:19.460 Wow. And so you said, Oh, so I'm number one.

00:02:23.560 Yeah. Can you imagine a teacher saying that today?

00:02:25.700 No, no, I do. You should, you're, you're a gentleman not to actually name the person and

00:02:30.020 shame them. Um, okay.

00:02:31.420 I'll remember his name too.

00:02:33.040 Should we do it? I don't know.

00:02:34.740 Nah, nah.

00:02:35.640 No, we'll skip it.

00:02:36.100 You guys probably not even alive anymore.

00:02:37.880 So you're feeling kind of mediocre and you're thinking like, maybe I'll make boxing my thing

00:02:42.800 that, that doesn't require great grades. It requires different skills, but I don't have

00:02:47.340 to be, you know, valedictorian to become a great boxer. And you were going to drop out

00:02:51.200 of high school in the 11th grade. And I love this piece of the story. Cause of course,

00:02:56.100 anybody who achieves the kind of greatness that you have, uh, there's a turn, you know,

00:03:00.440 there's the moment of the turn and your turn, um, was brought about in large part, thanks

00:03:07.080 to a man named Woody Sparrow. Great name, Woody Sparrow. What's the story?

00:03:12.520 Yeah. Well, actually it was, it was 12th grade, believe it or not. Um, and Woody was my math

00:03:17.640 teacher. Um, and it's funny, it's weird that I was still taking math because it wasn't a required

00:03:24.620 subject beyond, I think the first three years of high school or something like that, but

00:03:28.100 I was taking it and, um, I liked him for some reason. I don't know why, but he was really kind

00:03:35.480 of the first teacher I had in a while that I really liked. And I remember just wanting to

00:03:42.900 be present in his class and wanted to do well. And little by little, I kind of started working

00:03:48.680 a little bit harder. Um, and I don't know, somewhere in the spring of that year, he said,

00:03:55.340 Hey, you know, Peter, can you come in a little early tomorrow morning? So I did. And he said,

00:04:00.020 look, I I've kind of heard from some of the other teachers. You're, you're not going to,

00:04:03.760 you know, you're not applying to university. And I said, yeah, that's right. And then in my mind,

00:04:06.960 I sort of thought, well, here we go. He's going to, he's going to give me the big lecture about how,

00:04:11.220 what a, what a waste of, you know, time it is not to go to college and all that other stuff.

00:04:15.620 And he said, you know, Peter, I, I gotta tell you, I really respect the fact that you've got

00:04:19.600 a dream that you're so passionate about. Um, and he talked about how, when he was young, he,

00:04:23.900 he actually wanted to be a professional hockey player and that was kind of his life.

00:04:27.320 But he said something that really kind of resonated that I think did change the

00:04:30.480 arc of my life. He said, you know, I think, um, I think it would be sad if you didn't go on to

00:04:37.180 university because I think you have a real gift for mathematics. And I think the world would be a

00:04:41.040 better place if you put that to use, but that was it. He didn't, he didn't give me any guilt trip

00:04:46.080 or anything like that. He just said, you know, I think you, I think you have a hidden talent here

00:04:50.120 that you don't recognize. Hmm. Did that resonate with you? I mean, it was apart from being flattered

00:04:55.060 and feeling good about, you know, receiving a compliment. Did you think, I also believe I might

00:05:01.820 have a secret math ability. I mean, I don't, I think I just loved, I mean, I, I guess it was the

00:05:07.380 first subject I really found myself enjoying. Um, of course, as time would go on, I would,

00:05:13.680 I would enjoy many other things, you know, intellectually, but at the time I saw a little

00:05:18.840 bit of what he was saying, at least in terms of enjoyment. I don't think I necessarily thought

00:05:23.320 I had something special, although I will say this is kind of a funny side, but you know, my parents

00:05:27.540 are both from Egypt. So we, um, you know, they immigrated to Canada and we're Coptic. So we're

00:05:33.900 kind of the minority of Egyptians. And of course the Coptics are the descendants of the Pharaohs.

00:05:38.280 And my mom used to always say this to me when I was, you know, doing horribly at school, she'd say,

00:05:42.920 you know, it's in your blood to be a scientist or a mathematician because, you know, you're a

00:05:48.540 descendant of the Pharaohs and look what they did. They built the pyramids, they did all these other

00:05:51.500 things. So I think like that was her kind of way of like trying to, you know, say, look, it,

00:05:55.560 it really is something you should be good at. Um, but nevertheless, I think when, when coming from

00:06:01.400 Woody, it meant a lot more, I think, you know, you sort of expect your parents to trick, try to trick

00:06:04.860 you into doing the right thing. But, um, yeah, look, I don't think Woody had any agenda. And I

00:06:09.960 guess, um, uh, I, I sort of believed him and came to realize kind of in the first risk-based

00:06:15.980 calculation I made in my life that the probability that I was going to end up as the middleweight

00:06:20.200 champion of the world was pretty low. Um, the probability, you know, pumping gas, uh, with brain

00:06:27.660 damage was pretty high. So I thought maybe I should give this other thing a shot. So I love that you

00:06:34.440 came from the Pharaohs. You're going to be great at math. You should consider science. Like it's in

00:06:38.680 your blood. My parents were more like you come from a long line of mediocrity and you are a chip

00:06:44.040 off the old block. Oh, okay. All right. Nail. So nailing it. All right. So you decide to give the old

00:06:53.480 math and science thing a try. Okay. That starts working out. Okay. For you, I guess it's as early

00:06:58.360 as 12th grade. And then can you explain what you did the young, well, it must've been 17, 18 year

00:07:04.800 old, you going into college, you did decide to go, uh, to sort of stay ahead in math and science.

00:07:13.260 Well, I think once I decided that this is what I wanted to do, I think the one thing I had going

00:07:17.700 for me and I think it's something that is important for any kid in, in, in school today in high school

00:07:24.120 or whatever is, I think it's really important, even if you're not completely fixated on school

00:07:28.840 to be really passionate about something. Um, and so, you know, whether that be music, the arts

00:07:35.340 sports, something like that, because when I did decide that, Hey, I really want to do this. I had a

00:07:40.760 lot of catching up to do. Um, and I only had one year to do it. So I had that 13th grade of high

00:07:46.820 school, that additional optional year, uh, in Canada. And I basically went from training six

00:07:54.080 hours a day, which is what I was doing for boxing to applying that obsessive compulsive nature to,

00:08:00.900 you know, basically trying to catch up on all the things that had to do with math and physics and

00:08:05.860 chemistry. Because by that point, what I decided to do was, um, go to, go to college, but study two

00:08:11.180 things at once. So I wanted to study applied math and mechanical engineering.

00:08:14.000 And so you wound up buying, as I understand, a copy of all the science and math and maybe the

00:08:21.380 engineering books as well prior to going into school. And you read them all before you had to

00:08:27.160 for class. Right. So after high school, I got all of the freshman books in, um, for calculus,

00:08:34.980 algebra, geometry, uh, probability, statistics, physics, chemistry, and actually hired a tutor.

00:08:40.400 So I went and found somebody who was, you know, a graduate student and, you know, took the money I

00:08:45.640 made working at the restaurant and sort of got through as much of it as I could, but I really

00:08:50.640 needed a couple hours a week with a tutor to take my questions to, and just, you know, kind of learned

00:08:55.840 everything that we were going to learn in the freshman year. And then when we got to the freshman

00:08:59.660 year, my technique was basically just when we're learning it for the first time in class, I'm going to

00:09:05.000 get to learn it for the second time. And I'm going to get to go a little bit deeper.

00:09:07.400 So, you know, if the professor assigns questions one through 30, um, I could do questions one through

00:09:14.260 60. Um, and yeah, that just, I think that what that did was, um, allowed me to more quickly get

00:09:22.020 through the fundamentals. Uh, I had this discussion with my daughter who's 13 the other day, which is

00:09:26.920 that one of the challenges of mathematics, uh, unlike English is it takes longer to learn the basics.

00:09:32.080 So in English, you can learn the basics, you know, by the time you're quite young, you can learn how

00:09:37.620 to read, you can learn how to write, you can understand sentence structure. And so very quickly,

00:09:41.060 you can get over to the sort of creative part of the language. You can write, you can read for

00:09:46.100 pleasure. You can do all these other things with math. It's harder, you know, there's a lot more

00:09:51.320 stuff you have to learn foundationally before you can get to the really creative, beautiful part of

00:09:57.520 math. And I think I, I just wanted to get there as quickly as possible. So I wanted to make sure I

00:10:03.040 could master all of the fundamentals of, you know, of calculus and real analysis and, you know,

00:10:09.480 all of that stuff. And until we get to complex analysis, and then you really start to get into

00:10:13.560 really interesting mathematics. That's fascinating. I've never, I mean, I never got to the stage of

00:10:18.560 life where I thought math was beautiful as opposed to just a constant stressor. Um, but it's also not

00:10:23.520 something most people do right before they go to sleep at night or while they're sitting on a train

00:10:28.340 ride or, you know, I mean, English reading that it's built into our lives in a way where it's

00:10:33.160 celebrated pretty much universally, whereas math isn't. So I do think if you have that aptitude for

00:10:38.120 it and the drive that you have, um, I, yeah, you can, you can take it to places the average citizen's

00:10:43.340 not going to wind up. So you do clearly have a big, beautiful brain, even though that guy in your

00:10:50.180 elementary school didn't see it. Um, and you wind at it at, you wind up at Stanford Medical School,

00:10:55.880 which is great. One of the top programs in the country. And as I understand it, then you go on

00:10:59.780 to do your Hopkins at, uh, your, your, your residency at Johns Hopkins general surgery,

00:11:03.980 and then you're to your fellowship with the National Cancer Institute where you studied immune

00:11:08.980 based therapies for melanoma. That was a particular area of research for you. Can we just stop there

00:11:14.200 for one second? Cause I'm fascinated by that. Um, melanoma is such a deadly cancer. And it's like

00:11:20.940 one of those things where, well, the key is not to get it. Well, uh, and my understanding of

00:11:26.920 melanoma is unlike like a basal cell or some of these other skin cancers, you can't really prevent

00:11:32.760 melanoma necessarily by not going out in the sun. It's like a blood cancer that may come for you or it

00:11:39.060 may not. You know, they look at your family history. I don't know, but I remember doing a

00:11:43.380 segment at NBC about these new therapies for it, like these blood therapies, these immune based

00:11:48.340 therapies that could potentially one day cure it. So what do you, what can you tell the average

00:11:53.960 citizen about that? Well, you're absolutely right, Megan. So unlike basal cell and squamous cell,

00:11:59.940 which are skin cancers that are non-lethal, uh, that are very directly related to your time in the

00:12:05.480 sun. Melanoma is a little bit less clear than that. Now it seems that there's some association

00:12:10.840 with, uh, early in life sunburns or the frequency of severe sunburns, but it's not, it's not as clear

00:12:18.400 a link and it's, it's clearly a much more difficult cancer to just say, here's the solution to not

00:12:23.760 getting it. Um, and so catching it early is essential. Um, but you know, the, the, the skin

00:12:30.780 lesions that ultimately go on to become melanomas can be very tricky. Um, and this is also a cancer

00:12:36.240 that, you know, afflicts young people as well. So, um, what's interesting about it, although it

00:12:43.320 wasn't known at the time, and by the time I mean, you know, sort of 40, 50 years ago, what wasn't

00:12:48.180 understood then that is clearly understood now is melanoma, along with a couple of other cancers

00:12:52.920 happens to have a lot of mutations in it. So I think everybody understands that cancer is a foreign

00:12:58.680 sort of thing. It's a genetic thing where our cells basically become foreign to us and they grow

00:13:05.740 without any regulation. That's effectively one of the two hallmarks of cancer, right? Is a cell

00:13:10.860 that grows without regulation. And then that cell has the ability to leave its place of origin and go

00:13:17.200 to a different place. That's what's called metastases. So those two principles effectively

00:13:21.760 decide is determine what cancer is now mutations, of course, must arise in the DNA of a cell to make

00:13:30.080 that happen. And on average, a cancer cell might have a hundred, 120 mutations. Melanomas have many,

00:13:39.380 many more mutations. And that turns out to create a little bit of a weakness for them because every time

00:13:45.640 a cancer cell has a mutation that makes it different from its non-cancer counterpart,

00:13:51.140 it gives the immune system one more chance to identify it and identify it as something foreign.

00:13:57.780 And if the immune system can recognize cancer as something foreign, you have a chance to smack

00:14:02.820 cancer. And in that sense, melanoma is fortunately one of the cancers for which we can now harness the

00:14:10.940 immune system to recognize it as what we would call non-self and therefore attack melanoma,

00:14:16.920 regardless of how advanced it is. So, I mean, is it a skin cancer or a blood cancer?

00:14:25.320 Well, it arises from the epithelium of the skin. So it is indeed a skin cancer, but it spreads

00:14:30.260 and it kills you by spreading. So there are very few cancers that can kill you without spreading.

00:14:36.180 Brain cancer is one of them. So glioblastoma multiforme, which is a very aggressive,

00:14:40.940 type of a brain cancer, it can kill you simply from the mass effect in the brain, the way it moves

00:14:46.220 out throughout the brain with its tentacles. You can't ever fully move it. And just due to the

00:14:51.460 nature of the brain being in a really finite space, any amount of excess pressure can be deadly.

00:14:57.860 But if you think about it, almost everybody you've ever heard of who tragically died of cancer died

00:15:02.340 because the cancer spread, right? No one dies because colon cancer is in their colon. They die because

00:15:07.200 colon cancer escapes the colon and typically goes to the liver or sometimes the lungs.

00:15:11.900 Similarly with breast cancer, a woman doesn't die from breast cancer because it ravages her breast.

00:15:16.480 She dies because it spreads to her brain, to her bones, to her lungs. And similarly with melanoma,

00:15:21.900 nobody dies because of what happens in the skin. They die because of how it spreads. And melanoma,

00:15:27.140 unfortunately, spreads very aggressively.

00:15:28.860 Well, the one good thing about melanoma is you can usually look for weird skin lesions. The thing

00:15:36.740 that's scary about like a pancreatic cancer or something, a lung cancer that creeps up on you is

00:15:40.880 you might not have any way of knowing that you have it until it's too late. Whereas melanoma,

00:15:45.380 generally, you will see something that looks just a little off if you pay attention. I watch this

00:15:51.200 carefully because I'm so fair. And I've told my audience the story before. I went to the one service

00:15:55.560 that they take the pictures of all your moles all over your body. You got to strip down naked and

00:16:00.040 they take all these pictures. Some strangers taking up close pictures of your freckles and

00:16:03.440 your moles or whatever. And then what I didn't foresee, Peter, is that then they send you those

00:16:07.800 pictures. And if you have the person at your mailbox collecting your mail as your assistant,

00:16:13.220 she gets an eyeful.

00:16:15.680 Yeah. But you raise an interesting point again, which is I think when you talk about the epithelial

00:16:22.480 cancers, which are the ones that basically kill most people, that's sort of 90% of cancer deaths

00:16:26.720 arise from these epithelial cancers, you can divide them into two types, those that are outside the

00:16:33.180 body and those that are inside the body. So melanoma is obviously, it starts outside the body of the skin.

00:16:39.320 And as you said, you can look directly at it. And by being able to look directly at it,

00:16:42.920 you have a window in which you can intervene before it gets advanced. But what a lot of people forget is

00:16:49.640 everything between the mouth and the anus is also outside the body. So esophageal cancer,

00:16:54.580 stomach cancer, colon cancer, these are also cancers outside the body. And that's why in my

00:16:59.840 view, I think it's unacceptable for people to die from those cancers. We have the technology to be

00:17:03.880 able to screen for those cancers. And furthermore, when it comes to colon cancer, which is one of the

00:17:08.680 deadliest cancers in this country, it always progresses through a very predictable stage of

00:17:16.800 polyp to cancer. In other words, every colon cancer starts as a polyp. And there's a period of time

00:17:23.440 where a polyp is benign. And that's, you know, most people who have had a colonoscopy probably

00:17:27.980 recall, yeah, I went and had my colonoscopy and the endoscopist said, you know, Mr. So-and-so, I

00:17:32.140 took three polyps, we snipped them, we took them out, we did a, you know, sent them to the pathology lab

00:17:36.780 and they came back normal. And that's a good thing because there's a chance that those polyps will become

00:17:41.460 ultimately malignant cancers. So it does break my heart anytime I hear of somebody dying of colon

00:17:46.660 cancer. And in a way it's strikes me as somewhat more tragic than say pancreatic cancer, where I

00:17:52.760 think we have far less of a handle on what the transition from normal to non-normal looks like.

00:17:58.920 And because it's inside the body, it's much harder to screen for. I will say this now that I, you know,

00:18:04.600 since I turned 50, that they wanted me to go get a colonoscopy. Can I tell you, I enjoyed it.

00:18:10.680 All right. This, this is why I enjoyed it. The prep, it wasn't as bad as everybody says. It was

00:18:15.780 fine. It was like not the most pleasant thing, but it wasn't anything to complain about. Then you go in

00:18:19.880 the next day and they give you the wonderful propofol, which is so great. Michael Jackson had

00:18:24.580 the weird Dr. Conrad Murray giving it to him every night so he could fall asleep. And that's what killed

00:18:28.560 him. But we're not talking about that. We're talking about just one fun dose of it where you count

00:18:33.040 back from 10. You don't even ever make it to eight and you wake up, you don't remember a damn thing.

00:18:38.820 You feel fine. There's no pain. You get a result that you can either do something about or, you know,

00:18:44.060 that you're happy to hear about if you stay on it and you get them regularly. And then you could

00:18:48.680 just spend the rest of the day in bed. It's wonderful. Yeah. I'm going to be 49 in a couple of

00:18:55.440 weeks and I'm having my third colonoscopy shortly. So I I'm a big proponent of doing this early and

00:19:01.220 actually doing it frequently, especially if even one polyp is taken. So, um, you know,

00:19:07.580 our practice is very much, um, outside of what the standard of care is, is recommended. Uh,

00:19:13.520 standard of care is moving towards 45 for your first colonoscopy, but typically has been 50 if

00:19:19.440 you don't have a family history. Um, and the reality is I think we're just missing too many

00:19:23.160 people when we do that. And we, when we screen infrequently and it's not to say that there's no risk

00:19:27.940 of colonoscopy. There is, you know, you have to make sure you have a really good endoscopist.

00:19:31.200 There's a risk of everything, including from the sedation. Uh, obviously a perforation would be the

00:19:35.880 most, uh, dramatic risk, but you know, I think these risks are very small and in the hands of the

00:19:42.600 right, uh, doctors, I think they're very manageable, but there's an asymmetry to missing a colon cancer.

00:19:48.480 Um, and again, when you, when you hear about these things and especially in people who are 40,

00:19:54.540 50 years old, it's just, uh, it's very difficult to stomach.

00:19:57.820 Well, and I think with that, with that procedure, there's some, I don't know,

00:20:01.460 cachet and sort of saying how awful the prep was and, Oh God, I got to have this thing done.

00:20:05.380 And it's of course in an area of the body that we don't really like to discuss with one another,

00:20:08.860 but I just want people to know it's, it's really not that big a thing. And, and no,

00:20:13.600 the prep these days is trivial. You're absolutely right. I mean, it is, it's not, it's not bad.

00:20:17.820 And then the day is an excuse to get off your feet and watch a bunch of real housewives or

00:20:21.720 whatever your poison is. Yeah. Just make sure people, if you're doing it, ask for either a

00:20:27.000 pill prep, uh, or a very low volume prep. Um, so back in the olden days, you used to make people

00:20:32.500 drink something called go lightly. So they had to drink, I don't know, something to the tune of like

00:20:37.080 four to six gallons of something that tasted horrible. It was really bad. And nowadays, you know,

00:20:42.940 like the prep I'm going to do in a couple of weeks is 12 to 20 pills taken over the course of

00:20:49.240 six hours and then a bunch of water. That's it. That's not bad. Um, okay. And by the way,

00:20:54.320 before I move off of melanoma and all that is, you know, the, the good news that you said about

00:20:58.220 the cells and the changing, and that takes the most, it gives the immune system another chance

00:21:03.060 to recognize it as foreign. Is there, I mean, are they making serious advances thanks to all these

00:21:08.860 immunotherapies that we have now? Are they making serious advances in fighting melanoma and those kinds

00:21:13.480 of cancers? Yeah, absolutely. Um, so, so there's sort of different levels at which the, um, immune

00:21:21.600 system can recognize a cancer. So if you start at one extreme end of the spectrum, you have

00:21:26.920 spontaneous remissions of cancer. Now these are incredibly rare, so rare that they're reported in

00:21:33.240 the literature anytime this happens. So this would be an individual who shows up with a cancer and it's

00:21:38.140 riddled their body. And then somehow they get miraculously cured. Um, it's not clear exactly

00:21:45.240 why their immune system finally recognizes that cancer, but it does. And it goes to war against

00:21:51.720 that cancer and it prevails. That's a pretty rare individual. Now, if you move a little bit over,

00:21:59.160 you have a, another small subset of people who, if you give them something called a cytokine,

00:22:04.120 something that revs up the immune system and the most commonly used cytokine and the most

00:22:08.560 efficacious is something called interleukin two, you give them a very high dose of this thing called

00:22:12.620 interleukin two, you will capture another small set of the population who with that priming of

00:22:18.320 their immune system undergoes the same thing. So they can have, you know, completely spread cancer

00:22:23.800 throughout their body. And now all of a sudden it goes away on, on, on behalf of the immune system.

00:22:28.460 Hmm. That was basically the state of the art until about 15 years ago. Then a third layer and a third

00:22:35.660 advanced came along, which was something called checkpoint inhibitors. Now these gained quite a

00:22:39.940 bit of fame when a former president, Jimmy Carter had metastatic melanoma, which again, historically is

00:22:46.460 a death sentence. That is a six month survival. And he was given one of these drugs, uh, Keytruda,

00:22:52.720 which is an anti PD one, uh, agent and miraculously was cured. So what do these drugs do? So what these

00:22:59.700 drugs do is they remove the brakes that are inherently built into the immune system. So

00:23:04.640 immune system has to have brakes on it. Otherwise it would just attack ourselves and we'd have lots of

00:23:09.920 autoimmunity. And in a subset of people, their immune responses are almost good enough, but not quite.

00:23:18.240 And by removing the brakes to their immune system, you unleash hell. And so that's kind of the next

00:23:24.360 layer. And we have two drugs, one that targets PD one, one that targets, um, another thing called

00:23:29.600 CTLA four, not important. Um, and so where are we moving now? I think we're moving into the next phase

00:23:34.740 and the next phase is the phase that's going to, I think, change the world of, of cancer. And that is

00:23:39.920 going to be something called, um, a combination of what's called adoptive cell therapy and till

00:23:44.900 therapy, tumor infiltrating lymphocytes. So the really good news is about 80% of people who have

00:23:52.540 metastatic cancer, the kind of cancer that's going to kill you actually have antigens, which are

00:24:00.540 things, you know, proteins that are produced by the cancer that are recognized as foreign by their

00:24:05.740 immune system. The problem is most of them don't have enough of those immune cells to do anything

00:24:12.420 about it. And so the real future here in oncology is being able to, um, produce more of those cells

00:24:21.000 so that people can in fact, you know, use their own immune system to eradicate their tumors. And I,

00:24:26.580 I really do think that that's what we're going to see in the next 10 to 15 years.

00:24:31.540 Is this why, when I asked my primary care physician about the COVID vaccine and whether I was better off,

00:24:37.260 this is in the early days with the Johnson and Johnson vaccine or with the MRNA vaccines,

00:24:42.340 he said the MRNA vaccines are safe. He said, um, and he said, you, you bet you should get used to

00:24:50.780 them because someday they're going to cure pancreatic cancer. So my view is that vaccines alone will never,

00:25:00.480 I shouldn't say never will not be sufficient to cure cancer. Um, I think that, and I could be wrong,

00:25:08.480 but my intuition, and this is based on 20 years of data is that vaccines by themselves won't be

00:25:15.920 enough. It will be imperative to also take, cause all a vaccine does is prime a cell that already

00:25:24.220 recognizes that vaccine into action. But I think what we're seeing today, and this is some of this

00:25:30.240 literature is not even yet published. So this is really new stuff is that the issue is not that

00:25:36.260 we don't recognize cancer. Uh, I think the work of Steve Rosenberg, my former mentor, um, which is,

00:25:43.180 this is work that partially is published. Partially is not yet published demonstrates that 80, as I said,

00:25:48.000 80% of patients have novel neoantigens to their cancers. So that's not a problem that a vaccine is

00:25:53.420 going to solve. That's a problem for which given that they're not, you know, curing themselves

00:25:59.180 is a numbers problem. You have to be able to get more of those cells into the hands of their body.

00:26:05.600 And, uh, I think that's going to require some bioengineering, right? It's going to require

00:26:09.840 the ability to identify those cells in the body, take them out and replicate them into the tens of

00:26:16.100 billions of cells and then infuse them. So that basically every person will get a different drug

00:26:21.720 to treat their cancer and the drug will be their immune system.

00:26:24.540 We'll be them. Right. How, how far out are we from that?

00:26:28.820 The good news is it can kind of be done right now for some cancers in terms of being able to do this

00:26:36.260 for any cancer. It could be 15 years. Um, because the, the, the challenge still is not identifying

00:26:46.300 the cells called lymphocytes that are capable of doing this. It's being able to have them preserve

00:26:54.120 their essence of killing while replicating them over and over again. Right. It's like,

00:26:59.440 it's almost a longevity problem of lymphocytes. It's, you know, we can find those subset of cells

00:27:05.240 in you that are the ones that are going to eradicate your cancer, but I have to keep them

00:27:10.080 young enough while I replicate them over and over and over again, especially when I put them back in

00:27:14.620 you, they still have the fight left in them. That's fascinating. Wow. No wonder you were drawn

00:27:22.440 into medicine and then this related field of longevity.

00:27:26.180 To take a step back on the subject of you, I want the audience to know, and I'm sure we'll run back

00:27:38.800 to this. You obviously became an obsessive studier and academic, and you became an obsessive swimmer

00:27:45.440 and accomplished all sorts of amazing, amazing feats. Swimming, I don't, I wrote down a couple of the

00:27:52.940 things. They didn't, you know, I'm not a swimmer, so it wasn't like I understood exactly what they,

00:27:57.700 what they meant, but I could see that you went far and you went, uh, in places that nobody had ever

00:28:04.480 expected you to go, given that you hadn't been a competitive swimmer until you were 20. You did

00:28:09.240 your first pool lap at 27, began your marathon open swimming at age 31, 2008, first male double crossing

00:28:15.600 of the Maui channel, uh, took you almost 11 hours and 45 minutes, age 34. You swam the widest point of Lake

00:28:21.720 Tahoe from California to Nevada in seven hours and 24 minutes at age 34, 2009, you cross the Catalina

00:28:27.100 channel. This is a big one from Southern California mainland to Santa Catalina Island, uh, in 14 hours,

00:28:33.740 eight minutes at age 36 from the LA times article covering that. All he wore was a swimsuit, goggles

00:28:40.780 in a cap, went 20.2 miles, been doing your residency while you were training for this, working a hundred

00:28:48.680 hours a week, then swimming three to four hours a day in the pool, then a swim each weekend of up to

00:28:52.820 eight hours in Northern Virginia, which is not far from Hopkins. Um, and so on. I'm pointing out that

00:28:57.320 many of these endurance swimmers begin in childhood, not you. So your wife who's quoted in the article

00:29:04.520 is right. Jill says he is an extremist in everything he does. How, how did you get like that? Because with

00:29:11.720 the boxing, then the academic focus, then the swimming, that pattern emerges pretty early in

00:29:18.780 your life. Yeah. I mean, look, I think lots of therapy, um, has helped me shed light on that

00:29:25.140 because I think there's some, there's some positives to that and there's some negatives to that. Um,

00:29:29.740 I think the positives are a lot of the things you're highlighting. Sure. It's, you know, it's what

00:29:33.600 allowed me at the age of 18 to basically go from being on the fast track to work at a gas station,

00:29:40.560 to being able to get a scholarship, to go to college and things like that. So, so there's,

00:29:45.400 I don't, I don't want to diminish the benefit of that internal, uh, milieu, but I also think there's

00:29:52.240 a drawback to it. Um, and I think, you know, a lot of it just has to do with, you know, things in my

00:29:57.140 childhood that, um, I think lots of, lots of kids go through and, and I think everybody kind of

00:30:01.820 processes things a little bit differently, but, but I, I think, you know, there were just lots of

00:30:05.880 insecurities and, um, you know, just a, a very significant need to, um, to, to gain self-worth

00:30:14.680 through achievement is probably what drove so much of that. This is my problem. I'm not doing

00:30:20.100 enough damage to my kids. I'm going to have to think harder about how to crush their little spirits

00:30:25.120 so they can go on to become successful. Anyway, tabling that Abby, could you just make a note,

00:30:32.600 crush the spirit research? Um, okay. So you decide like a lot of,

00:30:37.580 like a lot of doctors and lawyers, which I also am, um, not too long into it. This kind of sucks.

00:30:45.760 This is kind of, this is really not actually how I wanted to spend my life. And you, you take a,

00:30:52.980 you turn, maybe a left turn, I don't know, a turn to longevity. So what, what does that even mean?

00:30:59.880 That's not like, that's not like I, I got out and I decided to teach like longevity. Is that even,

00:31:06.080 was that even like a recognized field that you could create a career in when you, when you left

00:31:10.860 medicine? No. And when I left medicine, there's a, there's a long gap between that and that. So,

00:31:17.520 so I left medicine actually two years shy of completing my residency in 2006. And that's a

00:31:24.480 very unusual thing to do. Usually when people leave their residency, they do so, you know,

00:31:28.820 in a year or two, you sort of, you realize pretty quickly, Hey, this isn't really what I wanted to do,

00:31:32.540 or you don't do residency at all. I mean, I think, you know, 10% of my classmates at Stanford

00:31:36.040 realized this is cool, but I'm going to apply my medical training to something else. Um, but that

00:31:43.040 was not me. I mean, I was the most gung ho, the most hell bend. Um, uh, but I had become also very

00:31:50.300 frustrated with everything that I was seeing and doing. And I, I felt like a lot of what we did was

00:31:58.320 very heroic, but didn't seem to move the needle much. We weren't, you know, we, you know, you talk

00:32:04.580 about pancreatic cancer. I mean, pancreatic cancer is a deadly cancer. It's the fifth leading cause of

00:32:09.720 cancer death. Um, but it's also the most lethal cancer, meaning it's the one for which if you get

00:32:15.160 it, your odds of survival are incredibly low on the order of about 5%. And we would do these very

00:32:21.100 heroic operations that, uh, would remove the pancreas and part of the, part of the bowel.

00:32:26.620 Um, and if you were fortunate enough to, to, to be able to do that operation, which is maybe 20%

00:32:32.800 of people that had pancreatic cancer were even early enough that they could do that operation.

00:32:36.980 It might only be that 20% of those people would be alive in five years. So I think I just became

00:32:41.540 a little disillusioned with that. And I became a little disillusioned with a number of things in

00:32:44.880 terms of the process by which residents were trained. And I think my wife just got very tired

00:32:50.040 of hearing me gripe about it and, you know, writing manifestos and things like that. And she was like,

00:32:56.920 look, I think you either need to just change the system where you should probably get out.

00:33:00.800 Um, and I decided to leave. My initial thought was to go back to graduate school and do something

00:33:06.760 very, very quantitative. So I was thinking about either going into finance or just doing a PhD and

00:33:11.820 something, you know, more mathematical. Um, I wasn't psyched about taking on more debt. I already had

00:33:18.840 so much of it from medical school. Um, so I ended up moving into a field of consulting. And, um, so,

00:33:25.720 so when I left medicine, I, I initially actually went and worked at a company called McKinsey and

00:33:30.800 company and did, um, you know, uh, consulting in, in credit risk and finance.

00:33:36.480 That's sad that, that you spent any time doing that. That must've been really eyeopening to you

00:33:42.280 that this was also not what you wanted to do. So eventually you decide to study something that's

00:33:47.260 going to be good for you, good for your fellow humans, good for the world.

00:33:51.600 And let's get into the study of longevity. So let's, let's start talking about it because I

00:33:56.960 didn't fully understand this definite, this definition. Is this your definition or is this

00:34:01.440 the definition of longevity? Um, as, as the, no, hold on. I wrote it down. It's basically your,

00:34:09.040 your lifespan and your health span together. So it's not just, Oh, she lived to be 126.

00:34:14.920 It's how well you're living along the way, not in terms of money, cars, all that. How do you still

00:34:20.960 have your mental facilities? Can you still move around? Are you still enjoying your life?

00:34:25.380 Yeah. Look, I don't think I could take any credit for that definition. I think any solid definition

00:34:30.380 of longevity includes both of those pieces, lifespan and health span. The lifespan part is a lot easier

00:34:36.580 to understand because it's sort of binary, right? You're either alive or you're dead. That's

00:34:40.360 kind of, it's a one or a zero. Um, the health span part is not only a little more nuanced and

00:34:47.040 difficult to understand. It's also the one I think people care more about outside of extreme. So

00:34:52.720 nobody thinks that someone dying at 60 is reasonable, right? That we would all agree that,

00:34:58.120 you know, when you hear so-and-so died at 59 or 61, that's, that's a very premature death.

00:35:03.060 But I think people are far less concerned with, am I going to live to be 84 versus 94? That's a,

00:35:10.080 that's a second or third order consideration for most people. What matters far more than that is

00:35:15.980 what is the quality of my life? And I think there are basically three things that make up quality

00:35:23.520 and two of them are very age dependent. The three things are your mind. Um, so cognitive prowess. So

00:35:31.440 that, that means, you know, sort of processing speed, memory, executive function, all the things that

00:35:37.220 kind of define your cognition. The second is the physical body. So strength, stamina, freedom from

00:35:42.780 pain, flexibility, balance, movement, all of those things. And then those two are obviously very age

00:35:48.480 dependent. The third one is not age dependent per se, but I think is equally important. And that is

00:35:53.900 your emotional health. So that's, you know, frankly, your, the state of your relationships is the

00:35:58.200 largest determinant of that, of that bucket.

00:36:07.500 All right. So on that first one, processing speed, memory, your cognitive abilities. Um,

00:36:13.180 I recently had a great guy on from, he used to head up AEI. Now he's at Harvard, Arthur Brooks,

00:36:19.260 Arthur Brooks. Yeah. And he was talking about, you know, the second half of life, um, talking about how

00:36:25.640 I'm having dinner with Arthur on Friday. I love him. Oh my God. I would love to be a fly on that

00:36:29.380 wall because when I was reading up on you, I thought of him and he was saying, when you get

00:36:33.860 to the second half, you're going to lose some of those things, not lose, but they're going to go

00:36:37.920 down. And that a smart move to be rather than get depressed about it or in denial about it, or to

00:36:45.080 fight what's naturally going to happen to you is to sort of switch your intelligence to a line that

00:36:51.560 does get greater as you get older, which is sort of the more wisdom line. You know, you may not be

00:36:55.960 able to process as fast as the young, uh, I don't know, data guys or idea guys at, you know, Facebook

00:37:01.480 or meta, but you have a wisdom that a 24 year old doesn't have, and you can learn to utilize that.

00:37:08.600 And I loved Arthur and I loved our discussion and I got so much great feedback, but I felt kind of

00:37:14.460 bummed out about the discussion thinking, is there, is it true that we can't do anything? Cause I will

00:37:19.940 say I'm 51 and I don't feel any of that so far. I feel no cognitive decline whatsoever.

00:37:25.400 And there's still a piece of me saying, maybe he could, maybe I'll be the one or could it,

00:37:30.960 is Arthur just depressed? You know, like, is there a way of, of avoiding this? And then I read your

00:37:36.440 stuff and I was like, okay, maybe there is more exercise. What is it? So let's talk about it.

00:37:40.800 Well, I mean, you know, so again, I think, I think when Arthur writes about kind of the difference

00:37:44.940 between fluid intelligence and crystalline intelligence, which are those two phases you're referring to,

00:37:49.100 look, I think everything is based on the application as well. Right. So I think for what

00:37:55.360 you're doing for a living it's probably less about the speed with which you can compute things

00:38:03.040 and probably much more about the logic with which you can think through things and the ability to

00:38:08.760 sort of be able to read a situation and pivot and think. And I think that's probably more dependent

00:38:13.940 on your experience than it is kind of the raw horsepower of your CPU. So even if your CPU

00:38:20.600 is not flying at the same speed as it was when you were 30, I don't know that you would notice it based

00:38:27.100 on the nature of what you're doing. Whereas if you were an engineer, you might notice it in a

00:38:33.040 different way. Using surgery as an example, there's no question that someone physically is sort of over

00:38:40.100 the hill by the time they're 40. But in surgery, you have two things that are working, right? You

00:38:45.660 have the physical body, the skill, the actual ability to use your hands, but you also have

00:38:50.420 experience. And when you layer these two things together, you'd probably find that a surgeon is at

00:38:57.600 his or her best long after they have physically peaked because they're still physically good enough,

00:39:04.360 but they're more than making up for that with their judgment and their wisdom. So I actually

00:39:09.320 think it becomes pretty complicated when you look at a given individual as to what the peak really

00:39:14.560 means. Now to your question, am I as smart as I was when I was 24? Not a chance. When I look back at

00:39:24.840 my notes and the types of things I was able to do, it's pretty remarkable. I'm probably

00:39:33.860 a fraction of that today, but that's okay. I don't need to be able to solve non-linear differential

00:39:43.020 equations in my sleep to have a fulfilling life cognitively. No, I can verify that.

00:39:51.500 But I still want to be sharp, right? I still want to remember things. For me, the most important of

00:40:00.640 these is executive function. That's probably the one that for most of us matters greatly. And that's

00:40:07.080 the one that when you start to lose it, that's your ability to solve complex problems. That's your

00:40:11.820 ability to think even abstractly and things like that. And reason. I love writing. So the ability

00:40:17.380 to sort of write a coherent argument out. That's something I don't think I'm going to lose. I might

00:40:23.160 not be as fast about it, but I suspect that we can maintain that for a really long time. And of

00:40:28.740 course, everybody listening to this knows somebody who's 95 who is sharp as a tack. So it's, you know,

00:40:34.400 is that 95 year old as sharp as they were as sharp as they were at 25? Probably not, but they're still

00:40:39.920 plenty sharp. Why is it so often that when you know that person, they're still working? Is it, you know,

00:40:46.580 chicken and egg? Which is it? Is it the working that keeps them sharp or are they so sharp that they

00:40:50.880 continue to work? I would bet it's a bit of both truthfully. I think like when I think about

00:40:58.240 retiring, I, it doesn't even make sense to me, you know, to me, retirement should be thought of as

00:41:02.780 mostly just a financial thing. Like when are you done working because you have to, that that's really

00:41:08.360 to me, the decision of retiring, but you know, the idea of I'm not going to do anything anymore

00:41:15.180 than play golf. That's, that's a very unappealing thought. Yeah. So I suspect that, yeah.

00:41:20.880 My husband and I were just in Paris over the weekend and, uh, I took a quick trip. A friend

00:41:24.280 of ours had a birthday and we went and celebrated and, um, it's such a great city. It's so beautiful.

00:41:30.340 It's so clean. My God, it's so much cleaner than New York right now. You walk through New York,

00:41:33.520 it's like the garbages are overflowing everywhere. We've had too long of this terrible mayor.

00:41:38.300 Hopefully they know that I will do better, but Paris is like, there's not a, there's not a,

00:41:42.200 even a full garbage can, any place you go, everything's been picked up. The streets are so clean.

00:41:45.920 You could eat off of them. It's in good shape. And we were like, Oh, maybe, you know,

00:41:49.360 when the kids graduate, they're all off in college. We'll come live over here for six

00:41:52.620 months. You know, I would never want to leave the United States permanently, but maybe we'll

00:41:55.140 go live there for six months. And I was thinking, yeah, I could do my podcast from there. You know,

00:41:58.740 it'd be easy. I could, I, in no way am I like, okay, my kids are done with school and now I'm

00:42:03.020 going to retire. I, I love my job. I would, I would be crushed to be not connected some in some way with

00:42:08.700 the news and commentary and just, you know, cultural observations and so on. So I can relate

00:42:13.740 fully to what you're saying. And I do think staying intellectually active has the same effects.

00:42:19.960 I mean, I mean, not identical, but sort of as staying physically active, right? On the body.

00:42:23.980 So you talk about all of that. I think they're both essential. Yeah.

00:42:26.340 You're, you're so big on exercise and I'm going to confess is where I fall down on the job. I haven't

00:42:30.960 been doing a good job of exercise for most of my life. I have, but not, not in the recent past.

00:42:36.380 And I am inspired because this is what you tweeted out recently. The good news,

00:42:41.120 we have a drug that is very effective at delaying the onset of death and preserving health span.

00:42:47.080 Yes. And then it goes on. This drug is called exercise and nothing else rivals it. And you go

00:42:55.880 on from there, but this, this seems like rule number one exercise. Yeah. I'm not convinced there's

00:43:03.960 any intervention that can delay death as long as exercise. So when you're talking about the

00:43:08.840 lifespan side of that ledger of longevity, um, I could think of some exceptions, right? If you took

00:43:16.100 somebody that has familial hypercholesterolemia, which is a genetic condition that gives you

00:43:20.360 cholesterol through the roof, that's probably someone for whom getting them on lipid lowering

00:43:25.520 therapy in their twenties will have a bigger effect on the length of their life over the next 80 years.

00:43:32.560 But, you know, I'd have to start thinking of those types of examples to come up with a scenario under

00:43:38.940 which there's an intervention that is more powerful than exercise to lengthen your life.

00:43:44.760 Wow.

00:43:45.640 Now consider something more important, which is even if exercise didn't lengthen your life one day,

00:43:54.040 I would still argue it is the single most important thing to do because of its effects on health

00:44:00.820 span. And remember what we said earlier at the end of the day, more people care about how well they

00:44:05.880 live and how long they live. The difference between 80 and 85 and 90 isn't nearly as important as what

00:44:12.740 you were able to do during that last decade. And the impact that exercise has on both your cognition

00:44:19.680 and your physical body, obviously is enormous. In fact, I don't think there's an intervention that has

00:44:26.420 a greater impact on your brain than exercise. Again, there are extreme examples that can violate

00:44:32.980 that. You're going to talk to Matt Walker and he'll explain to you that if someone has really,

00:44:36.580 really horrible sleep, it's going to compromise their cognition. And absolutely that's true. And

00:44:40.820 it's going to increase their risk of dementia. But when you go outside of sort of the pathological,

00:44:46.860 I think exercise is really hands down the most important drug we have to preserve our body and to

00:44:53.840 preserve our mind. Oh, okay. So the next question on everyone's mind is what kind, you know, do I do

00:44:59.360 the, the pounding hit class where I, you know, I have to do tons of intensive cardio or do I go to

00:45:05.560 the gym and lift weights or do I do Pilates and what kind? So again, if you're sort of arguing this

00:45:12.760 from the standpoint that I would argue it, which is through total longevity, which means how do you

00:45:18.300 extend life and how do you enjoy life better? It's going to be a bit of all of the above in the sense of

00:45:23.660 it's really about strength, stability, aerobic efficiency, and anaerobic power. Those are really

00:45:29.880 the four components that we break exercise down into. And each of those must be trained for with

00:45:38.660 a very deliberate sense of what you're doing. You know, I think that the biggest challenge with

00:45:43.240 exercise is that most people are kind of rudderless, you know, they sort of, you sort of know it's

00:45:48.820 important. You're, you, you, you kind of know I should be doing this thing, but there's very little

00:45:53.160 specificity around what they're doing. And I believe that if you're going to really train to be

00:45:59.420 kind of a kick-ass person in the last decade of their life, you need to train with the specificity

00:46:05.420 of an athlete. Now it doesn't mean you're going to be training like you're a football player,

00:46:09.280 player. But if you think that Tom Brady isn't very specific in what he does to prepare for what he

00:46:17.200 did for the last, you know, 22 years, um, that's crazy, right? If you know, any, you pick any athlete

00:46:23.580 at the top of their game, nothing they're doing is not deliberate. And we have to be the same way.

00:46:29.340 If we're trying to be incredible 90 year olds, uh, and our training has to be predicated on those

00:46:36.560 four fundamental pieces. So how would that look? You know, for the, I know you've got a,

00:46:42.000 a amazing, uh, regimen that you do, but for the rest of us, average humans, what, how could that

00:46:50.360 work realistically for, you know, the, the busy people listening to the show or watching it?

00:46:54.760 Like what's realistic, what would you say to kick it off? I mean, I always start, I start with the,

00:47:00.080 I put the question to, to a patient the other way. I would say, what do you want to be able to do

00:47:05.160 in the marginal decade of your life? I call the marginal decade of your life, the last decade of

00:47:09.500 your life. So we're all going to die. Therefore, we will all have a last decade of life. Um,

00:47:15.160 you don't know when you enter the marginal decade, but you know, when you're there,

00:47:19.160 right? Most people kind of know when they're in that last decade of your life, but it's not entirely

00:47:22.860 clear the minute you enter it, but nevertheless, we can get a sense of who we're going to be in that

00:47:28.200 last decade. And I ask people to tell me what they want to be able to do.

00:47:34.140 I mean, if I have to do it in great specificity, right? So I, I don't want to hear, oh, I just want

00:47:38.900 to be able to, you know, move around pain-free and to play with my grandkids. It's like, no,

00:47:44.420 no, no. It's got to be much more granular than that. Like, I want to know exactly how you want

00:47:48.920 to play with your grandkids. I want to know exactly where you want to be hiking. I want to

00:47:53.800 know exactly how many steps you want to be able to walk up exactly how many pounds you want to be able

00:47:58.640 to carry, you know, that kind of stuff. Once you have that roadmap and we use this model,

00:48:04.700 we call this the centenarian decathlon, right? So, you know, what do you want to be able to do?

00:48:08.700 What are the 10 things that you want to be able to do physically at the end of your life in that last

00:48:13.080 decade? You then work backwards from there and you say, well, first of all, doing those things

00:48:18.920 implies that you can do this. So for example, to be able to climb so many stairs with, you know,

00:48:26.000 X pounds of groceries implies you have a VO2 max of this. And if you have VO2 max of that,

00:48:31.860 when you're 85, how high does it need to be when you're 75 and when you're 65 and when you're 55 and

00:48:38.540 when you're 45, because all of the things that you want to be able to do, you're getting to get worse

00:48:43.400 at as you get there, obviously. So you have to be able to start from a high enough position where you

00:48:48.960 are currently. So that by the time the glider gets down to that last decade, you're able to still

00:48:56.000 meet your objectives. So there's no question you're going to be deteriorating. You just want

00:49:01.540 to make sure that you get your base up high enough that the deterioration still lands you in a good

00:49:07.220 place. Exactly. And I want people to go through that process, which is called backcasting. So in

00:49:13.980 other words, don't sit here where you are today and try to forecast where you want to be. Go to the end

00:49:18.720 of the line and backcast to where you are now, because most people are going to be in for a rude

00:49:24.080 awakening. Well, I was just going to ask, how late is too late to begin this?

00:49:30.220 It's never too late, Megan, but look, it's like saving for retirement. If a 60-year-old decides

00:49:38.660 that they want to save for financial freedom, they're going to have a harder time doing it than

00:49:43.580 a 40-year-old. And it's the same here, right? If a person is 60 and they've never exercised a day in

00:49:50.380 their life, it's not too late to start. But I'd be lying to them if I said that they're not going

00:49:55.860 to have a much harder time achieving ambitious goals than someone who starts at 40. Yeah,

00:50:01.680 you're not going to land in the same place as that other person unless you just go to an extreme

00:50:07.820 level. I got it. So we should cover a couple of those. Aerobic, I think we get, you know,

00:50:18.380 aerobic, aerobic activity. Get yourself moving, get yourself breathing heavily, get yourself,

00:50:23.560 you know, whatever it is. I mean, I actually like the real aerobics. That's sort of how I paid the

00:50:27.900 bills when I was younger. But it could be biking, could be walking, could be, you know, classes. It

00:50:32.780 could be also anaerobic. I don't think everyone knows what that is. Can you explain that?

00:50:37.820 Well, there are just two ends of basically, you know, a spectrum, which is everyone kind of has

00:50:43.940 a sense of what cardiorespiratory fitness is. This is the fitness that involves basically your heart,

00:50:49.540 your lungs, and the oxygen extraction and metabolic systems within the muscles. Now,

00:50:54.120 at the low end of that spectrum, we call that zone two. And that's, you know, the area at which

00:51:01.200 you are maximally able to utilize both glucose and fat to extract energy called ATP using oxygen

00:51:10.320 at the other end of that spectrum. So that's, that's the low end aerobic. And that's where you

00:51:14.820 want to be spending the majority of your quote unquote cardio time. That's like when you get on

00:51:20.060 the bike and they say, would you like to be in the fat burning program? You're like, yes, that won't

00:51:25.160 take you to the anaerobic. You've got to get the heart rate higher. You got to get it out.

00:51:28.340 Correct. And, and, and that, that whole sort of, you know, unfortunately there's a, there's a really

00:51:32.600 rigorous way to know when you're in that zone. And it's unfortunately not what machines and gyms tell

00:51:38.580 you, but we'll put that aside for the moment that it's, it's clearly lower end intensity,

00:51:43.840 but at the other end of that spectrum, you have a much higher end and anaerobic is, is much higher.

00:51:49.240 That's correct. The anaerobic end all of a sudden is not something that you can sustain for very long

00:51:56.000 and, and it's a spectrum, right? So, you know, there's anaerobic that you can withstand for 40

00:52:01.640 minutes. Um, and then there's, you know, peak anaerobic that you could probably only withstand

00:52:06.060 for 90 seconds. So we're talking about that energy system and it depends how fit you are, right? So the,

00:52:12.480 you know, the fittest athletes in the world could, could be at a low anaerobic threshold for,

00:52:18.360 you know, nearly an hour basically. Um, but everybody's got some limit and, um, you do need

00:52:26.220 some training at that level, at that sort of peak level of maximum oxygen utilization and slightly

00:52:34.140 beyond. And we measure that using something called a VO two max. Well, it turns out that that's that

00:52:39.800 metric VO two max is one of the few areas in all of medicine where a more is better approach.

00:52:48.100 Seems to be the case. You know how very few things in medicine kind of just get better. Like the more

00:52:53.420 you do them, right? You know, it's sort of like, um, everything exists in an optimal range, blood

00:52:58.940 pressure, glucose, hemoglobin, all these things exist in sort of an optimal range. Too much and too

00:53:04.240 little is a problem. So it's all about the Goldilocks range, but VO two max meaning maximal oxygen

00:53:11.280 utilization pretty much just exists on a continuum of more is better. The higher your VO two max,

00:53:18.220 the longer you're going to live as a general rule. Wow. And so, um, and it's not subtle by the way,

00:53:24.940 Megan, like it's, if you, if you break people down into categories, um, into, and so one of the papers

00:53:32.160 I often cite on this, and I think it was in that tweet that you mentioned, you sort of look at the

00:53:36.580 bottom 25% of the population. We call that, um, low. You look at 25th to 50th percent of the

00:53:44.080 population. We call that below average 50th to 75th percent of the population above average

00:53:49.360 75th percent of the population to 97.5 is high. And then elite is the top 2.5% of the population.

00:53:58.320 And if you compare the risk of being in that top group, the top 2.5% of the population to the bottom

00:54:05.660 group, bottom 25% of the population, there's a five fold hazard difference in all cause mortality,

00:54:12.660 five X. I mean, that's a staggering difference. Same age. If you're assuming same age of these

00:54:18.100 people. Yeah. I mean, an easier way to think about this is when you consider the adjusted hazard ratios

00:54:25.200 for things that we know are deadly. So I think everybody understands that

00:54:28.840 type 2 diabetes, high blood pressure, and end-stage kidney disease are deadly conditions.

00:54:36.060 The first thing you said was smoking. Sorry, you faded out. Okay. Got it.

00:54:40.480 So, so, you know, smoking, I think has a hazard ratio of about 1.41. So meaning it's about,

00:54:45.460 you know, it's going to increase all cause mortality by 41%. You know, high blood pressure,

00:54:50.280 type 2 diabetes, end-stage renal disease has a hazard ratio of about 2.75,

00:54:54.440 2.8, meaning it's about 175 to 180% increase in all cause mortality. Now, when you compare somebody

00:55:03.320 who has low cardiorespiratory fitness, meaning they're in the bottom 25% of the population for

00:55:08.460 their age and their sex, and you compare that to someone who is above average, who's in the 50th

00:55:14.520 to 75th percentile, that's not heroic, right? You don't, you're not winning the tour de France there.

00:55:18.980 Just that difference is about a three-fold hazard ratio, meaning it's as significant as comparing

00:55:27.880 someone who's got normal kidneys to someone who's got end-stage renal disease, which by the way,

00:55:32.800 is more deadly than smoking and type 2 diabetes. How do you figure out where you, where you are in

00:55:39.220 that scale? So you have to take this test called the VO2 max test, and I'm not going to lie, it ain't

00:55:45.440 pleasant. How do we get it? So it's, how do we do it? It's an exercise physiology test. You could do

00:55:49.300 this anywhere. You can, you know, any, any place you live, you look up VO2 max test and the way the

00:55:54.440 test is done, it's usually done on a stationary bike or on a treadmill. They hook you up to a mask

00:55:59.280 that, you know, plugs your nose and it's got a little gas sensor. So it's measuring how much oxygen

00:56:05.280 you utilize and it's measuring how much carbon dioxide you produce. And you're put in a situation

00:56:11.420 where you're exposed to more and more work. So you're going to have to ride against more and

00:56:15.800 more resistance or run or faster and faster or up a steeper incline. And it basically makes you do

00:56:21.180 this until you can no longer utilize oxygen. So until your utilization of oxygen by your muscles

00:56:27.120 hits a maximum level, and that's known as your VO2 max. And then that number is normalized by your

00:56:32.880 weight. And you can check where you rank because this is all published data. So you could say, well,

00:56:38.820 I'm a female and I'm 51. So according to that, here are the five buckets and you'll see where

00:56:44.140 you fit in. Would you call your doctor and ask for this test? Like who, your cardiologist? Like

00:56:48.860 how do you get the little, the face thing? Yeah. You can just do it anywhere. I mean,

00:56:52.980 obviously if you're, if you're old enough, you'd want to make sure your doctor was aware that you

00:56:56.740 were doing this. But of course, any good place that you would go to do this would do an EKG on you

00:57:01.340 to make sure you were okay. But no, these are things that are usually done in exercise physiology labs.

00:57:05.260 Oh, that's so fascinating. My gosh. Okay. So you get your news and if you have bad news,

00:57:10.520 you got to work on getting your VO2 up. You got to get higher and it requires aerobic activity and

00:57:15.880 it requires anaerobic activity. The, the really pressing yourself, you know, tough spot of the

00:57:21.480 workout, but strength training, also a piece of it. You mentioned that. I mean, I think we understand

00:57:26.220 that just from watching our parents get older, you know, they seem unstable. And then stability was,

00:57:30.760 that was the other thing, you know, like they do seem unstable. My mom does for sure.

00:57:34.480 Um, and you know, you worry about them falling all the time and it's, it's like, you know,

00:57:38.900 the life cycle tends to be, you know, when you, when you're a sandwich generation, you, and you've

00:57:42.980 got the little ones like the two-year-olds and then you got the parents who are also 80, you see so

00:57:47.900 many similarities with all due respect, ma. Uh, but you know, like they're wobbly. And the fundamental

00:57:52.440 difference though is when you, when your two-year-old falls, they, they roll with it. When an 80-year-old

00:57:57.320 falls, it is so often that that fall begins a spiral towards basically the end of their life. You know,

00:58:03.620 they break a hip and they're never the same again. So that's stability and strength training,

00:58:08.160 no, to, to try to avoid that. Yeah. And, and stability is more than just balanced. Um,

00:58:14.560 stability really comes down to connecting the body in a way that, um, rids us of a lot of the

00:58:22.760 movement patterns that we develop as adults. So I sort of buy the argument that, and this is not an

00:58:29.460 argument unique to me, right? This is, I think many kinesiologists would argue this, right?

00:58:34.420 Kids are born largely correct. Um, the ability that they have, the way they use their hands,

00:58:41.400 their feet, the way they move is the way we were sort of designed to move. And then we do a lot of

00:58:47.920 things to them that sort of change that. I think we put kids in shoes a little too early. We generally

00:58:53.600 sit them up before they're ready to be sat up. We put them, you know, in little Bobby chairs to try to

00:58:58.280 make them walk before they're ready to walk. And we sort of go through these processes and then we

00:59:04.360 can become, you know, kids in school and we're stuck in chairs all day. Now this thing that we're

00:59:09.140 doing right now called sitting is, is quite unnatural to us. It's really not something we

00:59:13.000 ever did until, you know, maybe a few thousand years ago, but, and even still very few people would

00:59:19.640 have spent nearly the amount of time we spend in this position, um, until maybe the last couple of

00:59:24.760 hundred years. So, um, it does a lot of damage to us and, you know, yeah, damages our necks. It damages

00:59:32.660 our backs, you know, our, our, our shoulders come forward, our ribs flare up. We develop all of these

00:59:38.480 horrible movement patterns and those all impact the way in which we transmit force to the outside world

00:59:44.620 and the way that the world transmits force to us. And that's kind of what the root of so many of the

00:59:50.080 injuries we have. So you mentioned Pilates. Well, Pilates is a great example of a system

00:59:54.980 that helps you reconnect that way. I don't do Pilates. I do something called dynamic neuromuscular

01:00:00.580 stabilization, DNS, um, which is another system that came out of a Czech school in Prague. Um,

01:00:06.400 but all of these systems, whichever one you kind of adopt, and I technically use multiple systems and

01:00:11.700 sort of loop them into one with the people that I work with. Um, they're all geared at trying to

01:00:17.640 get me back to moving like a two-year-old is moving. Oh, that's so interesting. Yeah. Pilates

01:00:23.440 people swear by it. And I've actually never done it, but, uh, they do say as you get older

01:00:28.920 to, to consider it more and it's hard, it's hard. All right. So that's, that can be a good stability

01:00:34.120 exercise and then strength training. So you've got to do it all. Would you say it's important to work

01:00:39.060 out every day with one of these programs? You know, the programming is, is, is, is largely a

01:00:44.440 function of how much a person is willing to do. Let's go back to the investment analogy. Um,

01:00:49.640 you know, if you're 40 and your aspiration is to have millions of dollars, when you, uh, are 60,

01:00:59.220 you're going to have to save a lot of money and you're going to have to have really good investments

01:01:04.880 that generate a high rate of return. So similarly, if you're thinking about that through the standpoint

01:01:10.280 of how much do I need to exercise, how hard do I need to exercise? How diverse and comprehensive

01:01:15.500 does my program need to be? It really comes down to what your goals are. So I can tell you that for

01:01:19.320 me, I have very lofty goals. You know, I want, I'm 49 now, and I hope I've got another 40 years or so

01:01:25.880 on this planet. And I want when I'm in my eighties to be functioning the way most people would look at a

01:01:32.640 very healthy 60 year old today. And as such, I have to train accordingly. And that means I'm

01:01:38.420 exercising every single day. Um, and I'm, you know, spending probably, I don't know, 12 to 14

01:01:45.880 hours a week exercising in all of these disciplines, right? That there's a significant amount of time

01:01:50.720 that's spent on stability, strength and aerobic exercise in particular. Anaerobic is probably the

01:01:55.100 one that is the least time consuming. I probably only spend about, you know, 45 minutes to an hour

01:01:59.920 a week doing kind of higher intensity exercise. Sure. By, by its nature. But so would you posit then

01:02:05.100 that those who are trying to stave off, uh, the loss of mental sharpness by doing a crossword puzzle

01:02:11.340 every day by, you know, doing brain teasers would be better served by getting involved in a program

01:02:17.980 like this? Or considering doing both. I mean, the evidence is pretty clear. There's nothing that is

01:02:24.540 more neuroprotective than exercise. So, you know, it's lots of people have suggested that, you know,

01:02:30.700 mental gymnastics and things like that are beneficial. The data would not suggest that

01:02:35.440 anything rivals exercise for mental clarity. What about food?

01:02:40.760 I think food plays an important role in this and it's probably second on the list. Um, but I don't

01:02:47.360 think it is as, at least according to the data. And again, I have to tell you, when I first looked at

01:02:51.720 these data, I didn't believe this. I, the answer seemed too glib to me. It was sort of like, come on,

01:02:56.920 exercise seriously. Like that's the best we've got. I mean, I thought there was really going to be

01:03:00.280 some hidden thing I hadn't learned of before, but, um, no, it turns out that exercise both through

01:03:06.980 its benefits, metabolically, vascularly, and hormonally, it just can't be beat.

01:03:13.880 Now I know on food, you are a proponent of something I, I love, um, and that's intermittent

01:03:20.260 fasting. And, you know, you've got the, the app and all that. And, and we did a whole podcast on this

01:03:25.820 over the summer because I do think it's, it's genius. And I think half the battle in

01:03:30.480 doing well at intermittent fasting. And I've said this the other day is to just redefine

01:03:34.920 how re reset, how you think about hunger, about the feeling of being hungry. You know, like we've

01:03:43.200 been raised to believe it's a bad feeling. It's a problem that needs to be solved as opposed to just,

01:03:48.580 it's a feeling and it's mildly uncomfortable, but it's not the worst thing ever. You know,

01:03:53.380 you can have a glass of water in most cases and get past the moment, but we've just sort of been

01:03:58.840 re it's been reinforced in us for decades and decades that it's a bad thing. It's a problem

01:04:02.600 that you have to solve. Um, so you, I, I know my audience, I've told them I do the 16, eight,

01:04:07.960 you know, where you only, you only have an eight hour eating window. And lately I've been doing a

01:04:12.160 little bit more of, um, the six hour eating window. This show helps me. I do it live from 12 to two.

01:04:18.500 And so if I can just get through the show, um, then I'll eat from two to eight. And it's actually

01:04:23.500 not as hard as you think it would be. You are hardcore. You only eat, I think, during a two

01:04:29.080 hour window a day and you're on the one meal a day plan. As far as I read, is that true?

01:04:36.200 Uh, it's not these days, uh, but I've been, I've, you know, I've done it all right. So I've,

01:04:40.080 I've, I probably spent the better part of gosh, a year or two only eating one meal per day. I've spent

01:04:47.100 many years doing really long fasts, you know, uh, on the short end, three days on the long end,

01:04:53.400 10 days of just water. Um, come on. So, um, but, but look, I think that time restricted eating

01:05:01.660 is a great way to practice caloric restriction. So, uh, you know, I think there is a benefit that

01:05:08.460 comes from a period of caloric restriction. And again, it all has to be kind of tailored to what

01:05:14.380 your goals are. Um, so it's, I want, you know, I want to be thoughtful about it, right? I don't

01:05:19.240 think this is the answer for everything. And I'll tell you when I have patients who are lacking in

01:05:26.080 muscle mass, this is not the first thing I'm turning to, right? Again, I'm far more adamant

01:05:32.180 about putting muscle onto somebody who's deficient in muscle mass, because it's not uncommon to see

01:05:37.240 people who don't have much muscle mass, who don't even have much body fat, whose bone density is

01:05:42.260 kind of suspect. And those are people I don't want ever restricting calories in any shape or form,

01:05:47.820 right? We're trying to build these people up, but for many people, that's not the problem.

01:05:52.340 They actually have a decent amount of muscle mass. They certainly have too much fat. Um,

01:05:56.660 and yeah, calorie restriction outright can be really difficult. You know, if I said,

01:06:01.700 Hey Megan, eat, you know, each or three meals per day, but every one of them is going to be,

01:06:05.860 you know, breakfast is going to be three grapes and lunch is going to be like some Malba toast and,

01:06:10.320 you know, whatever. And, you know, I mean, you die. Sometimes it's just easier to say,

01:06:14.680 Hey, how about don't eat anything except for six hours. And then during the six hours,

01:06:18.560 eat reasonably. Well, that for many people, that's a far easier thing to do.

01:06:23.000 Yeah, definitely. So is it true though, that intermittent fasting not only can improve

01:06:28.040 the way your body looks, uh, and the way it feels, but your lifespan, your longevity, that

01:06:34.280 low calorie intake, if you can keep it low could extend, extend your lifespan.

01:06:41.180 You know, I think when it comes to humans, it's very difficult to talk about nutritional

01:06:46.740 interventions that absolutely increase lifespan. Caloric restriction is hands down the most

01:06:54.120 notable dietary intervention across all animal models when it comes to increasing lifespan. So

01:07:00.700 when we think about the science of longevity, we talk about how we study this in, you know,

01:07:06.620 mice, fruit flies, worms, yeast, all sorts of organisms. And these are organisms that span a

01:07:12.600 billion years of evolution, by the way. So when you study something across a billion years and you

01:07:16.740 always get the same answer or mostly get the same answer, it generally tells you something good is

01:07:21.340 going on. And while caloric restriction doesn't always work, it works more often than any other

01:07:26.980 dietary intervention. Um, and it does extend lifespan. Now there are exceptions to this rule.

01:07:33.020 For example, it doesn't seem to extend lifespan in mice when started late in life. It doesn't seem to,

01:07:38.560 and mice we think are more relevant because they're far closer to us than all those other animals I

01:07:43.300 discussed. Um, it doesn't seem to extend life on all types of mice. And it certainly doesn't seem to

01:07:50.800 extend life in the wild. It might reduce the risk of certain things like cancer, but it also might

01:07:57.840 seem to improve, uh, increase risk of other things. Um, for example, immune, uh, based things such as

01:08:04.520 infection. So anything where your immune system can get weaker. So I think for the sake of humans,

01:08:10.380 what we can probably say is caloric restriction that doesn't get anywhere near malnutrition

01:08:18.280 is probably valuable provided it does not impede lean mass, which is muscle mass.

01:08:24.820 Yeah. You need that. And you, you say that basically 80% of the deaths, the non-smoking deaths,

01:08:30.300 uh, that happened to humans are, well, you, can you phrase it that the three categories that you,

01:08:36.040 you put most of the deaths in? Yeah. I kind of call these the, the, the four horsemen,

01:08:40.540 which are basically three huge categories of death. And then a fourth one that sort of serves as the,

01:08:45.160 there's the foundation of them all. So the, the first one of these is the atherosclerotic diseases.

01:08:50.720 Uh, so cardiovascular disease, cerebrovascular disease, this is not just the leading cause of

01:08:55.520 death in the United States. It's also the leading cause of death, death in the entire world,

01:08:59.460 which is kind of remarkable when you consider that that includes the developing world,

01:09:03.880 right? That's heart attack and stroke. That's right. Okay. The second is cancer. So that's the

01:09:08.920 second big horseman talked about that already. Yeah. The third horseman is neurodegenerative

01:09:14.320 diseases of which dementia is the most common and of which Alzheimer's is the most common form of

01:09:19.320 dementia. And, you know, this is one where you see a huge outsized shift in the last two decades of

01:09:26.260 life. So when you look at people over 75, that one really starts to explode. And interestingly,

01:09:31.820 cancer starts to actually come down a little bit. So cancer on a per age basis really kind of peaks

01:09:38.160 in middle age. So kind of fifties and sixties is where we see cancer as the most common cause of

01:09:44.020 death, but then it sort of becomes eclipsed by heart disease and neurodegenerative disease. So

01:09:49.480 those are the three really big horsemen. And then the fourth one is what I call metabolic disease.

01:09:55.180 And when I say what I call, I mean, I, I think what anybody would call metabolic disease, which is

01:09:59.240 the spectrum ranging from, you know, insulin resistance to non-alcoholic fatty liver disease,

01:10:04.520 all the way up to type two diabetes. And while those diseases by themselves don't really kill

01:10:09.800 that many people, um, they, I believe are underrepresented in our mortality table for the

01:10:16.520 impact that they have on the other three horsemen.

01:10:24.040 So how do you prevent yourself from, I mean, I think generally we know cardiovascular disease,

01:10:29.980 you have to eat a certain kind of diet and you are supposed to exercise. Like we know that, um,

01:10:35.860 cancer depends, right? Like don't smoke, but doesn't necessarily mean you're not going to get

01:10:41.040 lung cancer. 20% of the people who get it never smoked. Um, there's other things you can do,

01:10:46.320 but none of this is a guarantee, but how do you prevent diabetes? All I know is don't eat too many

01:10:52.380 sugary foods, right? Like, is that basically it?

01:10:55.580 I think the two mainstays of avoiding diabetes are absolutely nutrition and exercise. Again,

01:11:01.100 everything keeps coming back to exercise, but what is diabetes? First of all, well,

01:11:04.960 it's a carbohydrate tolerance disorder. It's a, it's a condition in which people can't,

01:11:10.460 uh, appropriately dispose of glucose. And so glucose tends to build up in their bloodstream.

01:11:15.680 And why can't they dispose of glucose? Cause what you have to say, well, where do we normally

01:11:19.520 dispose of glucose? Well, we have two places. We put glucose. Every time you eat a carbohydrate,

01:11:23.580 you basically have two places to dispose of that immediately. One is in your liver and the other

01:11:28.800 is in your muscles, but your muscles are by far the biggest reservoir. So around 75% of your glucose

01:11:36.700 storing capacity is indeed in your muscles. So anything that impairs your ability to put glucose

01:11:44.020 into your muscles is ultimately going to lead to type two diabetes. And the hallmark of that process

01:11:51.000 is something called insulin resistance. Insulin is one of the most important hormones in the body

01:11:56.080 secreted by the pancreas in response to glucose levels. And it is the hormone that tells the muscles

01:12:04.000 and the liver to some extent to bring glucose out of the circulation inside. And so, you know,

01:12:10.240 when you think about type one diabetes, which is a disease that shows up much more commonly in young

01:12:15.220 people, that's an autoimmune condition, the body is attacking the pancreas and eroding the part of

01:12:22.480 the pancreas that makes insulin. So those people end up getting very high glucose levels because they

01:12:26.820 don't have enough insulin. And so the treatment for those patients is actually to give them insulin,

01:12:30.780 but type two diabetes is a totally different disease. This is a disease that actually starts out

01:12:35.580 with too much insulin because the muscles become resistant to the effect of insulin. And as the muscles

01:12:42.160 become resistant to the effect of insulin, the pancreas must make more and more and more insulin.

01:12:47.280 And eventually that works, right? So that sort of keeps the glucose coming in, but at some point that

01:12:51.680 stops working. And then the glucose levels just become too high in the bloodstream. And that's the

01:12:56.140 definition of type two diabetes. So it's really a supply demand problem. You're eating too much glucose

01:13:02.360 and you're not creating metabolically active enough muscles to dispose of that glucose.

01:13:07.400 So when we talk about eating, like your dietary habits, is there a way of, you know, exercise? Yes,

01:13:13.600 we know, but is there a way of preventing getting type two diabetes? Like the Mediterranean diet? I know

01:13:18.180 you're not big on these like, do keto, do paleo. You're not that guy at all. But is there something we

01:13:23.520 need to know in terms of preventing this?

01:13:26.340 Well, I have a very, um, and I appreciate you noting that I just can't stand dietary labels and stuff

01:13:31.900 like that. I mean, uh, you know, I, I think if, if, if one were going to give a nod to one diet,

01:13:36.780 I think you would have to give it to a Mediterranean diet based on the clinical trials,

01:13:40.220 right? So if you're going to look at all the data and I say this as someone, by the way,

01:13:43.880 who's personally done all of this, right? I mean, in residency, I was vegan for six months.

01:13:47.880 Uh, later on I was keto for three years. So I, you know, those are like, that's like being a

01:13:53.680 Catholic and a Protestant at the same time. Right. So, um, I will say the, a Mediterranean diet

01:13:59.900 has the best outcome data supporting, you know, all cause mortality and cardiovascular disease in

01:14:06.700 particular. But I think that that's not nuanced enough, right? If I just said, oh, Megan, all you

01:14:12.280 got to do is go eat a Mediterranean diet. I mean, what does that even mean? I'll just Google it.

01:14:15.320 You can have so many different ways to interpret that. So instead I try to think of this very

01:14:20.500 agnostically and without label, which is, you know, and I use something called a continuous glucose

01:14:26.980 monitor on myself and with my patients, which is kind of a crazy idea to some, because this is a

01:14:31.240 device that's normally only worn by people who have diabetes. So it's a little, you can't see it

01:14:35.620 because it's under my shirt, but it's a little device that I wear on my arm. Come on, show us.

01:14:39.480 Just kidding. Just kidding. Take my shirt off. Yeah. I guess I could have worn a short sleeve

01:14:45.880 shirt if I thought further ahead. So, um, but basically this device tells me in real time what my

01:14:51.520 glucose is. So I get a real sense of how, what I'm eating is impacting my blood sugar.

01:14:57.620 And so I'm not, I'm not waiting for sort of a hidden surprise one day where I show up and my

01:15:02.000 doctor says, oh my God, you've got diabetes. Of course not. Like I, I see, oh, you know what?

01:15:07.000 When I had like that fourth bowl of cereal, that was probably a little too much. My blood sugar went

01:15:11.480 to 170. That's probably higher than it should be. So I kind of like taking this personalized

01:15:17.180 approach to carbohydrate, uh, based on that, because, you know, back when I was a cyclist and

01:15:22.560 I was riding my bike four hours a day, I mean, I, yeah, I couldn't eat enough carbohydrates. Like

01:15:29.440 it, you know, so, so to, you can't compare what I was eating then to what I'm eating now. I was

01:15:34.620 eating six to 800 grams of carbohydrates a day. Wow. Today, I probably only eat 250 grams of

01:15:42.620 carbohydrates a day. And if I eat too much more than that, at the current level of exercise,

01:15:49.040 my glucose is going to be higher than I want it to be. So that's, that's kind of how I think about

01:15:53.600 carbs. Let me add, while we're on the subject of diet and the Mediterranean diet, um, having just

01:15:58.980 come back from Paris, you know, they're big on their cheeses and their chicken and, uh, their protein,

01:16:05.820 they like their protein, but they're also big on the wine. And it was remarkable. I mean, everybody,

01:16:11.680 everybody everywhere was drinking lunch and dinner. I mean, every single table of the restaurant was

01:16:16.240 like, okay. And then it was like capped off with on the air, on the airplane ride home. We got to

01:16:21.700 the airport super early. We had to be there because my husband's incredibly in love with getting there

01:16:26.540 too early, just like Abby. Uh, we got there, it was like five 45 and a six 45 in the morning.

01:16:32.540 Sure enough, all these people are drinking then like a six 45 in the morning. What are you people doing?

01:16:36.740 So talk about alcohol and its effects. Well, contrary to, uh, to the French paradox,

01:16:43.760 I would argue that the French, if they do indeed live longer, it's, it's despite that,

01:16:47.620 not because of that. I think the data are pretty clear on alcohol. Um, somewhere between zero and

01:16:53.460 one drink per day probably has no negative effect. Um, so, you know, and there's some debate,

01:17:01.040 but I've looked at these data. So in every possible way, uh, written about this, that I, I don't believe

01:17:09.860 that zero is worse than one. So there's some view that there's actually a J curve and that, you know,

01:17:15.880 the perfect number is about one drink a day. I think that's untrue. I think it's that basically

01:17:20.700 somewhere between zero and one drink per day, there's really no discernible difference. So if

01:17:26.440 there is a difference, we don't have the resolution to measure it, but once you exceed one drink a day,

01:17:31.340 there is a clear and consistent increase in risk and it becomes greater and greater, the more it goes

01:17:37.020 up. So it becomes non-linear in terms of risk. Um, it's important to understand ethanol is toxic.

01:17:43.280 I mean, full stop. It is, it is the fourth macronutrient. So you have carbohydrates, fats, proteins,

01:17:49.460 and alcohol. Those are the four macronutrients. It's highly caloric, right? It's, it's almost as dense

01:17:55.280 calorically as fat, right? Almost twice as caloric as protein and carbohydrate. Um, and it is full on

01:18:02.500 toxic. So it's basically, we can tolerate a little bit of this toxin, right? To the tune of, you know,

01:18:10.560 15 grams a day, um, which is about the amount of alcohol you'd have in a glass of wine or a beer

01:18:16.160 or a shot of tequila and anything beyond that, you're starting to get into some chronic toxicity.

01:18:21.400 So when I say toxic, I don't mean acute toxicity, right? The way that, you know, you're going to die

01:18:26.300 if you drink three bottles of tequila, that's an acute toxicity. That's very rare, but I'm talking

01:18:31.200 about the chronic toxicity that comes from consuming something. So, you know, my view on alcohol is,

01:18:36.640 that's funny. You mentioned the, uh, the airplane don't drink on airplanes. That that's sort of my,

01:18:41.620 my heuristic for how I think about alcohol, because at least the airplanes I fly on, the alcohol is not

01:18:47.940 that good. Like they're just giving it to you to sort of numb you from the experience of flying.

01:18:52.440 So if I'm going to drink, it's going to be good. So I am a little bit of an alcohol snob actually.

01:18:57.300 Um, so there's certain tequilas, there's certain wines, there's certain beers that I really fancy.

01:19:02.340 And that's the only stuff I'm drinking. Um, so I'm never drinking for the sake of drinking.

01:19:06.520 And yeah, I probably have three to four drinks a week. Um, but I make them count.

01:19:10.980 And you're never doing like three drinks. No. Yeah. I mean, sometimes I'll have two,

01:19:17.360 but that's pretty rare again, just sort of keeping in. Cause the other thing is, you know,

01:19:20.980 now getting into sort of sleep, um, alcohol is such a devastating hammer when it comes to sleep.

01:19:26.660 I mean, if you want to come up with a way, if you're, if you're looking for a strategy to destroy

01:19:30.720 your sleep, um, just drink. So, but what, what does it do, right? Like what you say,

01:19:37.500 the damage of the touch, the toxicity, but what does that mean? How does that manifest?

01:19:42.440 Well, with, with the effect of sleep, it's probably the creation of aldehydes and things

01:19:46.560 like that, that really impair REM sleep. That seems to be the disruption that we see on the brain

01:19:52.660 from alcohol in proximity to bedtime. So if you, you know, you, you, you know, if you look at the

01:19:58.060 different stages of sleep, you have kind of these two light stages of sleep, stage one and stage two.

01:20:03.320 No, and we do cover this with Matt, but I just mean in general,

01:20:06.200 if you're not going to be an alcoholic with cirrhosis, what are the, what are the risks to

01:20:11.360 you? Well, at the extreme ends, you have all of those things. Of course you have fatty liver

01:20:16.600 disease. So that's probably the biggest metabolic downside of alcohol is the infiltration of fat in

01:20:24.540 the liver. Even if it does not progress to cirrhosis, cirrhosis is a very extreme state,

01:20:29.200 but long before cirrhosis, you get to inflammation. Long before you get to inflammation, you get to fat

01:20:33.520 accumulation. This exacerbates insulin resistance. So the thing to keep in mind is that the body

01:20:39.480 always wants to burn alcohol before it's going to burn anything else. So there's a general hierarchy

01:20:45.160 with which the body wants to metabolize things. But when alcohol is present, it basically prioritizes

01:20:50.960 that metabolism. So I always find it ironic when someone says, you know, I'm really trying to lose

01:20:56.360 a few pounds and they're drinking alcohol. Because when someone says they're trying to lose a few pounds,

01:21:00.240 what they really are saying is I'm trying to lose a few pounds of fat, right? If you're trying to lose

01:21:03.700 a few pounds of fat, really the last thing you want to be doing is drinking alcohol.

01:21:06.760 So if you're trying to choose between that bowl of ice cream and a glass of wine, because you need

01:21:11.480 to have your one treat and you want to lose weight, but you have no willpower because you're having a

01:21:16.360 bowl of ice cream or a glass of wine, choose the ice cream. Well, I don't know. I mean, all things

01:21:21.200 being equal, typically the ice cream would be far more caloric than the glass of wine. But if you're

01:21:26.400 anything like me, and I think most people are like this, typically the more alcohol you drink,

01:21:30.820 the more it reduces your inhibitions around food as well. So sometimes it ends up being the worst of

01:21:35.720 both worlds. If I'm going to have two drinks, which I don't have often, if I do, I'm more likely to

01:21:41.820 eat something I otherwise wouldn't eat. Well, and then you get a crappy night's sleep and then you

01:21:45.900 really overeat the next day. And we talk about that with Matt too. Like a bad night's sleep is a

01:21:51.240 great recipe for a terrible day of eating. Okay. Let's talk about Alzheimer's and these

01:21:56.380 cognitive declines, these diseases that were the third horseman, because, you know, those are scary,

01:22:02.480 right? Because as you point out, you know, you drop dead of a heart attack. It's not great,

01:22:07.740 but it's not the worst way to go. Some cancer deaths can be quick. Alzheimer's is like you're

01:22:14.440 sentenced to this life of loss day after day and losing the people around you while they're still there.

01:22:20.240 And then they are sentenced as well to watching you. It's just so painful and so awful. I think

01:22:27.100 most of us would do anything to avoid it. So how do we? You know, I think the good news is despite

01:22:33.120 how frightening Alzheimer's disease is, and I think you're right that if you ask most people, what are

01:22:38.480 you afraid of more than anything in aging? Certainly when I ask people that question, the most common

01:22:45.040 answer I get is just that. Um, on the one hand, it's the disease we know the least about relative

01:22:51.640 to cancer and, um, cardiovascular disease. But I think we also have a pretty good handle on

01:22:57.580 prevention there. Um, you know, the adage, what's good for the heart is good for the brain is almost

01:23:03.920 always true. There is probably one exception, but when you think about all the steps that one takes to

01:23:10.460 reduce their risk of atherosclerosis. So reducing lipids, reducing blood pressure, reducing glucose,

01:23:17.860 reducing all the inflammatory markers that go into it, exercising, sleep, nutrition, all those things

01:23:23.580 that you're going to do to have the most heart healthy existence. They're absolutely doing the

01:23:28.060 same thing for your brain. Another kind of sort of tongue in cheek heuristic I say is what's good for

01:23:34.780 the liver is good for the brain. So if you start to think about all the things that are involved

01:23:38.580 in metabolic health, insulin sensitivity, you know, not having fatty liver disease,

01:23:43.600 not having visceral fat, all of those things, they also tend to do wonders for the brain.

01:23:49.660 And then I think exercise is this important thing. There's, you know, exercise is a drug. It produces

01:23:54.980 a set of hormones. It produces a set of chemicals that are basically like candy for the brain. So we,

01:24:00.360 we were, you know, we just never want to lose sight of that. I think there are some other things

01:24:03.880 and perhaps the most interesting of them is the use of sauna, which is again, something that I was

01:24:07.700 kind of suspect of for many years. I kind of had seen the literature, most of it out of Finland.

01:24:12.780 Sauna?

01:24:13.760 Yeah. Yeah. Sauna use.

01:24:15.600 S-A-U-N-A, like the sauna, the thing that's next to the hot tub?

01:24:19.520 You got it. Yeah.

01:24:20.680 What?

01:24:21.860 Yeah.

01:24:23.300 Keep going. Fascinating.

01:24:24.620 Yeah. If you look, if you look at the literature out of Finland and you look at the dry sauna use,

01:24:29.520 the reduction in neurologic mortality and cardiovascular mortality is, you know, frankly,

01:24:37.720 on the tune of 50 to 60%, provided it's done at the levels and doses that, that, that they're,

01:24:46.020 that they've observed. So that's, you know, being in a dry sauna.

01:24:48.660 That's an easy, enjoyable thing. It's the first thing you said that sounds great. You got to get

01:24:53.240 rid of ice cream, got to get rid of alcohol, got to exercise two hours a day. When the hell do I

01:24:57.960 get to sit in the sauna?

01:24:59.220 Well, so the dose appears to be, um, at least 20 minutes, at least four times a week, at least

01:25:06.980 180 degrees Fahrenheit.

01:25:08.820 Oh, I'll do it. That's great news. Why? What? Just like the heat, the heat of it?

01:25:14.640 Well, it seems to be a bunch of things, right? So it, it forces the body, you know, in some ways

01:25:19.580 it's kind of like a low end, it's, it's sort of like a low intensity exercise, right? If you've

01:25:23.500 been in a sauna, especially one that's that hot, there's 180 degrees is, you know, anyone who's spent

01:25:28.980 time in a sauna will recognize immediately. That's not comfortable. And after 20 minutes in there,

01:25:33.560 you're, you're pretty psyched to get out. Um, but your heart gets pumping. So you, I think you've

01:25:38.820 got this vascular benefit. You, you're, you generate these things called heat shock proteins that

01:25:43.400 basically, you know, at the risk of oversimplifying kind of clean out a lot of the junk in the

01:25:48.240 body. Um, so I think it's a combination of things about sauna that probably render it

01:25:53.640 quite beneficial. Not, uh, think of it as another stress, right?

01:25:57.320 It's not the same as steam or getting in a super hot shower or bath.

01:26:02.560 The good question. We don't have data on those things. I get asked that all the time. I also get

01:26:07.700 asked, Hey, is, is a, is an infrared sauna the same? I don't know because the, all of these data,

01:26:14.560 uh, that, that I can point to on this subject matter are all based on dry sauna. So, um, it's,

01:26:20.720 it's hard for me to extrapolate, uh, without, you know, what else is there on the good list? What,

01:26:25.800 what is there another little secret on that side of the ledger that we can do?

01:26:29.180 I mean, I think the other thing is probably managing cortisol, right? So I think that,

01:26:36.160 uh, stress is a killer. I mean, again, it's sort of a cliche, but it's a cliche for a reason

01:26:41.420 because everybody knows deep down it's true. Um, and stress is less about the stress that's

01:26:47.000 on you. It's more how you internalize that and how you process that. I think you can take

01:26:52.300 three people that are under the exact same situation, but if they have a very different

01:26:57.000 manner in which they internalize and process that they could end up in, in totally different

01:27:02.260 situations. So I think that, you know, hypercortisolemia, which is kind of a technical

01:27:06.860 way to explain what's happening when you're under so much stress, uh, is clearly harmful,

01:27:11.640 right? It's, realism is horrible. It's effect on the excess cortisol. So if you know,

01:27:20.740 it's effect on metabolism. Is that what you said? Okay. So yeah, it's effect on metabolism. It's

01:27:25.000 horrible. It's effect on the cardiovascular system is horrible. Uh, it's effect on the

01:27:29.280 brain is horrible. I mean, it basically shrinks the brain. So, you know, too much cortisol is a

01:27:34.760 bad thing. And I think the more we can look to things that minimize that the better. In fact,

01:27:40.580 that might be some of the benefit that sauna and exercise have, because for many people,

01:27:45.720 these things are activities that help us blow off a bit of stress.

01:27:55.000 It's therapy. That's one thing you can do. Mindfulness, like meditation. Are you a fan

01:27:59.280 of that? I am. Yeah, very much so. Okay. And other than that, I don't know, isn't that

01:28:04.180 partially luck of the draw? Like I know people who just seem their default is anxious. And then

01:28:08.700 there are others who are like, yeah, I'm good. And so if your default is anxious and you're using

01:28:13.180 those tools, what about medications? Yeah, I think medications play an enormous role. Um, I think

01:28:19.340 they're, you know, probably, I think people, you know, the way I explain this to people is

01:28:24.200 these medications rarely work in isolation. They tend to work really well when they're accompanied

01:28:30.180 by really good talk therapy as well. So antidepressants by themselves have reasonable

01:28:36.920 efficacy, but not great efficacy. Um, but when you combine an antidepressant with effective

01:28:43.140 psychotherapy, it actually has a huge impact and effective psychotherapy comes down first and

01:28:48.680 foremost to the connection that the patient has with the therapist. Uh, that turns out to matter

01:28:53.180 more than the qualifications of the therapist, for example. So, um, you know, I have a few therapists

01:28:59.660 and they are all a really important part of, uh, my, my mental health. And it's, it's taken me a while

01:29:05.440 to find the group of therapists that I have. And I had to go through a number of them until I got there.

01:29:09.820 And I encourage people to do the same thing, which is if I introduce you to somebody and you don't

01:29:14.500 connect with that person, then let's find somebody else. Because until you really have a great

01:29:18.620 connection with somebody, it's very difficult to, to kind of go deep on the, on the stuff you need

01:29:22.920 to. So when you say, you know, you're still seeing patients, like what do you, cause I know about your

01:29:28.120 podcast and I know about your app, which I should mention to people, it's called, uh, the zero Z E R O

01:29:34.140 app. And that's the, the intermittent fat, the fasting app. Um, but what, I mean, are you,

01:29:40.220 do you have like a center or a, a practice where people can come to you and get all this stuff done?

01:29:46.040 And what is it like executive healthcare described it to us so that we can replicate it in our own

01:29:50.560 lives? Uh, yeah, we, I do have a practice. Uh, it's a, it's a really big team. So I've got a group

01:29:56.440 of other doctors that I work with, uh, exercise specialists, nutrition specialists, um, a research

01:30:01.680 team that supports both the practice and the podcast. Uh, and so it's all kind of under one

01:30:06.200 umbrella. Um, early medical is what it's called. And where are you? Um, well, it's so it's a virtual

01:30:13.200 practice now. So historically the practice was, uh, bi-coastal between New York and California,

01:30:19.020 but, um, about a year and a half ago, when I moved to Texas, kind of at the beginning of COVID,

01:30:24.360 um, you know, it didn't make, we weren't, no one was traveling. So it kind of shut the offices down

01:30:29.100 and we were, we moved everything to virtual and figured out we could do everything that we do

01:30:33.280 virtually. And once COVID sort of went away, we just thought, Hey, we don't, we don't need to go

01:30:40.380 back to an office and, and it never really made a lot of sense because people always had to come

01:30:43.920 to see us. You know, our patients are really all over the country and in different parts of the

01:30:49.040 world. So, um, an office doesn't really make sense. So our, our practice is a virtual practice,

01:30:53.720 but, um, you know, I'm based in Austin and one of our physicians is in California. One of our

01:30:59.080 physicians is in New York. Another one is in, uh, Virginia. So, so people are spread out all over

01:31:03.820 the place. But this is so much better than what you were doing, because as you point out,

01:31:07.720 you were studying cancers and trying to sort of play run and catch up when somebody had something

01:31:12.820 bad diagnosed. And now it's all about prevention and staying ahead of the game. And none of this

01:31:19.340 is a guarantee, but you're in it, you're swinging, you're fighting, right? It's like, there's comfort

01:31:25.440 in that. And even if you don't win, right? In other words, you, you do get a disease, um, you're living

01:31:31.840 well. I mean, we haven't really even talked about just the way you feel day to day in eating well,

01:31:37.120 exercising, reducing alcohol consumption, being mindful and so on.

01:31:43.280 Yeah, that's exactly right. I mean, prevention is kind of a cheap word, um, because, you know,

01:31:48.660 it's, it's, it's sort of a buzzword in medicine. Oh, you know, prevention matters, but the reality

01:31:52.760 is it doesn't really matter that much in medicine. Like if you, I mean, and not to, not to be too,

01:31:58.620 you know, mercenary about it, but medicine only does what medicine gets paid to do.

01:32:02.780 All right. So we, we live in a system where, you know, a physician has to be able to bill

01:32:09.400 for a service, right? If you go to your doctor, they have to be able to bill for something to get

01:32:15.920 paid. That's, that's the way the world works. And those billing codes are based on what an insurance

01:32:21.440 company deems reimbursable. So prevention just doesn't really create that much of a billing

01:32:28.600 attractiveness. And therefore, um, when you look at what most physicians have to deal with

01:32:35.320 when they're in primary care, which are really the frontline physicians that would be the natural

01:32:40.840 owners of prevention, they can't do it economically, right? They have to see, I don't know, 20 patients

01:32:48.300 in eight hours, if not more, I've talked to physicians who have to see 40 patients in eight

01:32:53.540 hours or 10 hours. Um, you're basically just putting out fires. And, um, so even though we

01:33:01.000 talk the talk, well, prevention is everything. We don't really give physicians the tools to do much

01:33:06.480 about it. And we certainly don't create the financial, uh, incentive structure for them to be

01:33:11.560 able to do it either. So this is what worries me because at this point in my life, I have the dough

01:33:16.900 to pay out of pocket and to get, you know, a great, great doctor who will spend two hours with me and

01:33:21.840 ask me all the questions and send me for all the preventative tests. And I can get reimbursed,

01:33:25.920 you know, after the fact by some, you know, some of it will get, but the, I remember what it was

01:33:31.440 like to have no money. And that version of me was on like the college healthcare plan. And then for a

01:33:37.640 while, no healthcare plan and would never have been able to do preventative tests or a colonoscopy

01:33:42.660 or any of that stuff. So for the people out there who either have like insurance or no insurance,

01:33:49.880 what can they do?

01:33:51.740 Well, I mean, look, it's, it's, it's really hard. I mean, I would say on the one hand,

01:33:55.380 the good news is that I think about 80% of what it takes to really achieve your longevity potential

01:34:04.680 is something you can do without a physician. I mean, think about all the things we've spoken

01:34:08.660 about today. I don't think we've really spoken about much that requires a physician.

01:34:12.480 You know, we haven't really talked about this drug versus that drug and all the cool molecular

01:34:17.200 pharmacology stuff that goes into this, because the reality of it is, I think that's 20 to 25% of

01:34:23.460 the game. I think most of the game comes down to how you exercise, how you sleep, how you eat,

01:34:29.180 how you manage stress. And so the good news is you don't need a doctor to do that. The bad news is

01:34:34.580 you still need the information. Um, and you know, I, I guess, you know, I hope that me and others,

01:34:41.040 people like Matt are able to provide some of that information so that at least there's enough for

01:34:45.740 people to kind of do it yourself. Now he has written a book into which he has put most of this

01:34:50.020 information. Um, have you done that? Are you going to do that? Where can we find your,

01:34:54.200 all of your thoughts written down? Well, uh, I am in the process of finishing a book that's been in,

01:35:01.140 in the works since 2016, if you can believe it, such a, such a difficult experience that's been,

01:35:06.940 but I'm getting there. So, uh, have a book that should be coming out in the first quarter of 2023.

01:35:13.640 Um, I write a weekly newsletter. Yeah. So, so a year from now. So I write a weekly newsletter

01:35:19.060 with my research team and that comes out every Sunday. How can people get that?

01:35:24.360 Um, they just sign up for it on, on our website. So peteratiamd.com and, um, you sign up and every

01:35:32.180 Sunday morning, you'll get a newsletter. So we're writing about this stuff every single Sunday. And

01:35:35.540 as you mentioned, we've got a podcast every Monday that's in our, coming up to our fourth year

01:35:40.520 where, you know, it's just, it's all this type of content that makes it easier and easier for people

01:35:46.200 to, um, you know, hopefully kind of see a little bit of a signal in the, uh, morass of noise.

01:35:51.760 Hmm. All right. Last question. Where can they get the little glucose monitor underneath their

01:35:55.740 armpit? Just Google those words. Yeah. Yeah. So, so they're called continuous glucose monitors.

01:36:02.680 There's probably two companies that make the majority of them in, um, in the U S and unfortunately

01:36:10.340 they are still, this is still something that you need to get a prescription from a physician for,

01:36:15.800 um, which is unfortunate. And I think that's a, an awful mistake on the part of the FDA to require

01:36:21.660 prescriptions for these things. I won't get into why they're doing that and why it doesn't make any

01:36:26.620 sense, but nevertheless, um, I think that's going to be changing. And I think that in the future,

01:36:31.320 people will be able to buy these over the counter just as they could buy a finger stick device to

01:36:35.540 measure their glucose. Yeah. Right. That's just less pleasant. This has been fascinating, Peter. I

01:36:40.660 learned so much and, uh, I'm really grateful to you for sharing your journey, your expertise,

01:36:45.660 all you've learned. And I feel like this, this is just step one. I feel inspired by you to start

01:36:51.080 living better so that I can live long and well and better. Well, great to hear that, Megan. Thanks

01:36:57.520 for having me on all the best to be continued. Don't forget to download the Megan Kelly show on

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01:37:13.740 really enjoy spending this time with you guys. And I appreciate you listening and downloading

01:37:18.280 and being there for us. Thanks for listening to the Megan Kelly show. No BS, no agenda, and no fear.

The Megyn Kelly Show - March 25, 2022

Importance of Exercise, Effects of Alcohol, and the Science of Longevity, with Peter Attia ｜ Ep. 286

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