The Peter Attia Drive - #04 - AMA #1： alcohol, best lab tests, wearables, finding the right doc, racing, and more

00:00:00.000 Hey everyone, welcome to the Peter Atiyah Drive. I'm your host, Peter Atiyah.

00:00:10.140 The Drive is a result of my hunger for optimizing performance, health, longevity, critical thinking,

00:00:15.600 along with a few other obsessions I've gathered along the way. I've spent the last several years

00:00:19.860 working with some of the most successful, top-performing individuals in the world,

00:00:23.440 and this podcast is my attempt to synthesize what I've learned along the way to help you

00:00:27.840 live a higher quality, more fulfilling life. If you enjoy this podcast, you can find more

00:00:32.100 information on today's episode and other topics at peteratiyahmd.com.

00:00:41.440 Welcome to the inaugural AMA, Ask Me Anything Not to Be Confused with Against Medical Advice.

00:00:47.960 After getting a lot of really good questions on Twitter and realizing that I didn't have the

00:00:52.120 bandwidth or wherewithal to respond to all of them, and especially in such a short period of time,

00:00:57.280 or a short period of space, rather. Bob Kaplan, who's my head analyst, and I put up a little

00:01:02.980 Ask Me Anything on Twitter post, and over the next week we gathered a bunch of questions. They were

00:01:08.120 amazing questions. We organized them. We got probably over 200. Obviously couldn't address

00:01:12.760 them all in this episode, but we kind of bundled them, and I think in many ways we got through

00:01:16.340 probably half of the intended content that people had asked about. So in this episode, Bob interviews

00:01:22.280 me. I didn't really look at the questions before or spend much time preparing,

00:01:25.660 but I also thought it would be more enjoyable that way. And I will say it went by pretty quick,

00:01:30.180 so I guess we were having fun. Depending on how people like this, I think this is a format that we

00:01:34.840 should probably repeat, and maybe we'll do this quarterly, depending on what the demand is for it.

00:01:40.600 And hopefully we can use this as an opportunity to sort of answer specific questions without

00:01:45.920 necessarily dedicating an entire podcast to some of the topics. So without further delay,

00:01:50.980 welcome to AMA number one, and hopefully it's one of many.

00:01:58.200 All right. Hey, Bob.

00:01:59.660 Peter.

00:02:00.160 Thanks for taking the train down this morning.

00:02:02.720 Absolutely. My pleasure.

00:02:04.380 What time did you have to get up today?

00:02:06.040 I got up at 3 a.m.

00:02:07.880 Was that because you had to catch the train that early, or is there any other reason you got up a

00:02:11.780 little early?

00:02:12.540 The train was at 5 a.m., so I got a little mini workout in before I got on the train. I wasn't

00:02:17.940 sure if I was going to be able to squeeze one in today. So we're going to do a double because

00:02:21.720 we'll work out after this.

00:02:23.200 Very nice.

00:02:23.900 Are you still doing the squat every day routine?

00:02:26.780 Yes. Literally squatting every day.

00:02:29.820 So this morning you just wanted to make sure you had some time for squats?

00:02:32.780 Just a little bit of time for squats. Yeah. Just work up to a daily max and get in,

00:02:37.100 get out, get the Uber, jump on the train.

00:02:39.460 Well, I think this is officially the first time you're being introduced by voice, at least to people,

00:02:45.100 although anyone who's been reading Nerd Safari will understand that you are my right-hand guy

00:02:50.500 on all things pertaining to blogging and being a nerd. You are the head analyst in our practice

00:02:59.720 and also a very close friend and probably one of the people who's had his foot furthest in my

00:03:06.240 butt to be doing a podcast. So if I'm going to do it, I was going to drag you into it.

00:03:11.500 And I guess this is our first experiment with an AMA. I think we probably stuck out a tweet like

00:03:17.680 two weeks ago. And how many people ask questions? I feel like there was like three or 400 questions

00:03:23.260 came in.

00:03:24.040 Yes, definitely over a hundred questions.

00:03:26.740 So, well, I haven't been paying attention to them, which is why I CC'd you on the tweet,

00:03:31.860 but I'm guessing you've aggregated them and I have a feeling I'm going to be hearing them.

00:03:37.100 Yes. So I don't think we'll get to all several hundred questions today, but I did put a bunch

00:03:43.720 of them into buckets so that I'm hoping to cover a lot of ground.

00:03:47.280 I'm all yours.

00:03:48.280 So let's start with alcohol.

00:03:49.860 It's a little early for that, isn't it?

00:03:51.520 Well, it's five o'clock somewhere.

00:03:55.740 So this question, I'm just going to read the whole question, but we'll cover the alcohol.

00:03:59.920 I think if there were more characters, I don't know, what is it? 280 characters now?

00:04:03.420 140 it used to be. So I think this person got all the characters in.

00:04:07.160 Thoughts on consumption of alcohol, marijuana. Are we sleeping enough? Ever tried cold water

00:04:12.460 therapy? And a shout out to Iceman Hoff, Wim Hoff. How can we best enhance brain function?

00:04:19.420 Are we working too hard? Are we too removed from nature?

00:04:23.040 Oh, Jesus Christ. I can't even remember the first question.

00:04:25.480 Alcohol. Thoughts on consumption of alcohol, which is a little generic.

00:04:28.740 Okay. So I put this into a couple of categories. The first is just a purely physiologic, what is

00:04:36.840 the effect of the molecule ethanol on the body? And just as I sort of talk about sugar or other

00:04:44.440 things, it's really important to understand that ethanol is a toxin, but of course the dose makes

00:04:50.420 the poison. Now, the thing that I think many people forget who are not in the world of toxicology is

00:04:56.980 that there is a probability distribution that drives the impact of a toxin on a population.

00:05:04.660 And there are going to be some people at one end of the spectrum who are largely unimpacted by

00:05:09.240 certain toxins, and there are going to be others who are not. And so ethanol is no exception to that,

00:05:15.660 just as, you know, Tylenol or pick your favorite poison could be. So again, Tylenol meaning like,

00:05:22.440 even though it's at low doses, very efficacious as an analgesic at high enough doses, it's hepatotoxic.

00:05:28.140 Okay. So start with position one. I'm not convinced that there is a single benefit to ethanol,

00:05:35.120 the molecule in the human body. So ethanol in its metabolic pathway, and it's uniquely

00:05:40.200 metabolized by the liver. One of the byproducts is something called aldehyde, which is a toxin.

00:05:44.640 It really has two, and this is a bit of an oversimplification, but it has two effects.

00:05:48.980 So there's an effect on the liver and then there's effect on the brain. The effect on the brain is what

00:05:52.280 people drink alcohol for. It's the buzz. It's the CNS depression that also comes with some euphoria.

00:05:59.400 So it's a bit of a paradox there because ethanol, its effect in the CNS is that of a GABA agonist and

00:06:05.280 GABA, of course, is a non-excitatory or depressing neurotransmitter. But I think as most people will

00:06:12.540 understand, certainly ethanol can have an excitatory effect. So you've got this brain effect of alcohol,

00:06:18.340 you've got this liver effect. The liver effect is, you know, very similar to that of sugar or

00:06:23.120 fructose. They have very similar metabolic pathways, not identical, but also not surprising

00:06:28.540 that they overlap given that fructose is fermented to make ethanol. So from that standpoint, no benefit

00:06:35.440 to ethanol. But again, different people tolerate it to different amounts. As a general rule, each

00:06:40.980 beverage, and I'm not talking the kind you pour yourself where they're a little longer, a little

00:06:46.060 taller, but, you know, like an ounce of distilled spirits is about 15 grams of ethanol. An

00:06:52.840 appropriate, you know, maybe four ounce glass of wine is also about 15 grams of ethanol, as is a

00:06:58.320 beer, you know, kind of like 10 ounces, 12 ounces, again, depending on the alcohol content. So as a

00:07:02.340 general rule of thumb, each drink is about 15 grams of ethanol. One of the things, if a patient asked me

00:07:09.600 this question that I'm thinking is, well, what's your liver function right now? And the best proxy we have

00:07:14.940 for that is the ALT, one of the transaminases. And, you know, so when I see a patient that's walking

00:07:19.900 around with an ALT, that's already at the upper limit of what we consider normal by range today,

00:07:25.480 which I do not consider normal, which is probably 42 on our lab, I consider below 20 normal. I'm

00:07:32.380 always asking the question, do they have fatty liver right now? And if they do, is it more in

00:07:36.620 response to ethanol or is it more in response to fructose? That said, I have at least two patients that

00:07:42.260 I've taken care of either in the past or currently who consume seemingly unbelievable quantities of

00:07:49.200 ethanol, some of them averaging between eight and 12 drinks a day. And by ultrasound, their livers are

00:07:55.280 normal. By LFTs, their livers are normal. Looking at COAG studies, every other marker you can look at,

00:08:02.000 their liver function is perfect. And these guys are sort of the genetic outliers who have a remarkable

00:08:07.820 tolerance to alcohol. So the point I'm trying to make here is I want to get a sense of how much harm

00:08:14.280 is coming purely in a hepatic sense from alcohol, and then make sure we're drawing a line well below

00:08:20.600 that. But the second point is perhaps the bigger point, which is the why. The why are we drinking

00:08:27.060 alcohol? And I say this as a guy who likes alcohol just as much as the next person. But certainly in my

00:08:33.100 life, I've started to ask, am I drinking just for the sake of drinking? Am I drinking because I'm

00:08:38.980 trying to soothe some other issue? And does my drinking lead to a behavior that I'm otherwise not

00:08:45.200 happy about? And in my case, personally, that generally tends to loosening the reins on what I

00:08:51.160 eat. And I don't think I'm unique in that. I've got many patients that when confronted will say the

00:08:55.840 same thing, which is, yeah, ultimately that's the problem with ethanol is you go out, you get a couple

00:09:00.500 of drinks in you, and things that you otherwise wouldn't eat, you just start eating. So not that

00:09:06.320 this is at all scientific, but my rule of thumb is the following. As a general rule, I don't want to

00:09:10.560 drink. If I'm going to drink, it's going to be good alcohol. I'm going to make it purpose-driven

00:09:15.700 drinking. So I don't drink on airplanes because the alcohol sucks. Like I'm not going to, just because

00:09:21.520 they're pouring me some half-assed glass of wine, I'm not going to drink it. But if I want to drink wine,

00:09:26.260 I'm going to drink wine that is exceptional. If I'm going to drink tequila, I'm going to drink tequila

00:09:30.140 that is exceptional. And if I'm going to drink beer, it's going to be exceptional. And because

00:09:34.520 somebody is going to ask, what are my favorites? My favorite wine is Clio, which is a Spanish blend.

00:09:39.320 And I've been drinking it since 2007. And I've had every bottle from 07 to 14. And I'm fully expecting

00:09:46.000 that people listening to this are not going to go and start buying Clio like crazy because sometimes

00:09:50.380 it's hard to find that I'm going to be really pissed off if I can't get it. Tequila, I know everybody

00:09:55.360 raves about 1942 and I think it's good, but the Classe Azul Reposado is absolutely my favorite.

00:10:01.820 It must be consumed neat, no ice, no lime, no nothing. And my favorite beer, I'm not willing

00:10:09.760 to say what it is because it is so hard to find. And honestly, not to be a selfish prick,

00:10:15.680 but I'm simply not willing to share it with anybody. One of the guys who works for me's part-time job

00:10:21.100 is sourcing it across the United States and Belgium. So I'm sorry, guys, I'm not going to

00:10:25.600 let on what that is. So that's my thoughts on alcohol.

00:10:28.680 Okay. Can I make a follow-up question?

00:10:31.000 Please.

00:10:31.120 Okay. So more or less, you said there's nothing beneficial. I'm sure you're going to get,

00:10:36.880 but what about the French paradox? What about red wine? Isn't a glass of red wine, maybe two for men,

00:10:43.140 maybe three, maybe six, depending on who you ask. Isn't that associated with better health

00:10:49.240 or less cardiovascular disease or more longevity?

00:10:52.380 Yeah. I mean, I think the red wine thing came about through two things that you mentioned.

00:10:56.720 One is the French paradox, which is, boy, the French seem to live a lot longer and they drink

00:11:00.880 more. Ergo, it's got to be that. Of course, I think that to get into that topic in detail would

00:11:06.140 sort of take the rest of our AMA and it really has to do with just a poor understanding of epidemiology.

00:11:11.600 So there are a lot of things that explain the French paradox. They also smoke more. I don't think

00:11:16.060 that that necessarily means smoking is better. So it probably has a little bit more to do

00:11:19.700 with what they eat than what they drink or don't drink. The other thing that I think has a lot of

00:11:24.480 people with this lingering idea that a glass of red wine a day must be healthy. And I want to be

00:11:29.140 clear. I'm not saying a glass of red wine a day is harmful, but I'm saying it's not benefiting your

00:11:34.620 health is the resveratrol story. So resveratrol is a compound that is identified in very small

00:11:40.980 quantities in red wine. And there was one lab in particular at Harvard that many years ago,

00:11:46.680 and I say many years ago, like probably 15 years ago, maybe 10 years ago, David Sinclair's lab had

00:11:51.640 studied this in high concentrations and they showed that it enhanced longevity. And that created like

00:11:56.460 this huge wave of everybody wanting to take resveratrol supplements. There are two issues

00:12:01.160 with this. The first is even if you believe those data, which I categorically do not, and no lab has ever

00:12:05.840 been able to reproduce them. And I'm not even convinced that Sinclair today would believe that

00:12:09.560 those were valid. You would not get that amount of resveratrol in a glass of red wine. So it's sort

00:12:16.120 of like the, uh, should I be eating more dark chocolate to live longer? Eh, maybe, but you're

00:12:20.220 probably better off just taking cocoflavonoids if you buy that that's the active ingredient that's

00:12:24.900 going to enhance nitric oxide production. The one thing I guess I'm glad you asked this follow-up

00:12:29.040 question, because I have some patients who will argue this. And honestly, maybe they're right,

00:12:32.620 which is, there are some patients who say, look, just a single glass of wine a day helps me unwind

00:12:37.660 a little bit. And isn't there any benefit in that? And I guess the answer is possibly.

00:12:41.640 And so the question is, does the net benefit of that, which could be a lower amount of cortisol,

00:12:46.940 a lower amount of emotional distress, could those things be beneficial relative to any of the

00:12:52.640 potential drawbacks of ethanol, such as, you know, increased, you know, appetite dysregulation,

00:12:57.780 or I'm not even getting into sort of pathologic behaviors. Maybe one thing I have observed in the

00:13:03.900 aura ring has made it very easy for me to track. This is one drink in the evening does not impact

00:13:11.300 my sleep two or more absolutely does. And does so in a profound way. The two things that happens

00:13:18.840 are my resting heart rate will be 10 beats higher. It will take very long for me to reach my resting

00:13:25.320 heart rate. So what you want is your resting heart rate to be achieved within the first

00:13:29.220 third of your sleep cycle. And more importantly, and perhaps more surprising to me is my heart rate

00:13:35.660 variability gets squashed. So I have a very low average heart rate variability when I have more than

00:13:42.040 two drinks. And even the volatility of my variability is very low. And that is reflected in my sleep. It also

00:13:51.000 definitely compresses REM cycles. So even though when you have a few drinks, you're groggy and you think

00:13:57.560 you're sleeping better, you're just less conscious, but you're actually sleeping worse.

00:14:01.640 Okay, let's move to the next one. Best lab tests. It's the bucket that I put this one under. So there

00:14:07.740 are a couple of questions at least. One question was what four to five tests can we go to our PCP or primary

00:14:14.640 care physician and request they run? Second question, what are the best lab tests as markers

00:14:20.120 for longevity? Well, so the first one is, and I guess you could divide these into things that you

00:14:26.620 really only need to have checked once and then things that maybe you ought to be checking more

00:14:31.660 than once. So a couple of things that everybody needs to have checked once is LP little a and APOE.

00:14:38.240 So LP little a is a phenotype, but it effectively reflects a genotype, the LPA gene. And we're going

00:14:45.540 to have an entire probably two and a half hour discussion on LP little a. So I'm not going to

00:14:49.540 say anything more about that, but suffice it to say, if you're listening to this and you don't know why

00:14:54.320 I'm suggesting that you will, but everybody needs to know their LP little a, preferably their LP little

00:15:00.780 a particle number, but the LP little a mass is to a first order, a reasonable approximation.

00:15:07.260 APOE of course is a gene and it exists mostly in three forms, the two, the three, and the four.

00:15:16.600 There are others, but they're almost, I've never seen one. And because it's a gene, you get one from

00:15:21.660 each parent. So therefore you can combine the two, the three, the four into six combinations, two,

00:15:26.980 two, three, two, four, three, three, three, four, and four, four. And it is important to know those.

00:15:32.280 In my opinion, though, I will certainly find myself arguing this point with physicians who

00:15:37.640 say, why the hell would you ever want a patient to know that there's nothing you can do about it?

00:15:43.320 Because of course this gene is probably the second strongest gene to predict Alzheimer's disease by

00:15:49.820 magnitude, but the strongest by far by frequency. In other words, it's the one that matters more at

00:15:54.260 the population level. I would agree with the logic of said physicians. If I felt that there was nothing

00:15:59.280 one could do to impact their chances of Alzheimer's disease, obviously, I think that that's sort of

00:16:05.140 nonsense. You and I, and Dan coauthored a paper with Richard Isaacson at Cornell and a few of his

00:16:11.920 colleagues on Alzheimer's prevention. So we're obviously in the camp that thinks Alzheimer's

00:16:16.280 disease is at least somewhat, if not significantly preventable. And therefore genotyping gives us great

00:16:22.760 insight. Furthermore, APOE genotype gives enormous insight into cardiovascular risk, something that

00:16:29.260 we probably ought to do a dedicated discussion around APO B, APO C, and APO E, just straight up APO

00:16:38.400 talk. I'd like to talk more about that now, but it's probably irrelevant. So you got to know your

00:16:42.380 LP little a, you got to know your APO E. The other thing that, again, I sort of think a lot about is

00:16:49.540 if LP little a is the single most important lipoprotein, then LDLP or APO B would be the next most

00:16:56.920 important. So that's also something that I really think ought to be tracked. Boy, we're only allowed

00:17:01.360 five, huh? Because I really, I guess I take for granted that we can just order lots of lab tests.

00:17:06.720 Can you explain, just sorry to back up, when you say LDLP or APO B, I think some people might think

00:17:12.040 like you can get either or test, but they're more or less testing for the same thing. Can you explain

00:17:18.020 how APO B relates to the LDL?

00:17:20.060 So there's actually two APO Bs. There's APO B 48, which is an apolipoprotein that sits on

00:17:25.720 something called the chylomicron. And then there's an APO B 100. And there is one and only one APO B

00:17:31.160 on each of the following molecules, VLDL, IDL, LDL, and also LP little a. So by counting the number of

00:17:41.760 APO Bs, you are counting the number of LDL particles. But because you measure APO B in mass,

00:17:48.660 it's measured as milligrams per deciliter of APO B versus LDL P is measured in number or nanomole

00:17:56.120 per liter. So the number will look very different. You know, if I said, tell me your APO B and your

00:18:00.240 LDL P, they will have different units and therefore not look anything alike, but they're

00:18:04.240 proxies for the same thing. And that of course changes. It's influenced by four things. It's

00:18:11.120 influenced by the amount of cholesterol you synthesize, the amount of cholesterol or sterol

00:18:16.500 that you reabsorb, the amount of triglycerides you have to carry around, and your clearance of

00:18:23.440 the particles, which is primarily driven by something called the LDL receptor or LDLR that

00:18:29.000 sits on the liver. And because those four factors can all change in response to diet and drugs to

00:18:37.040 different extents, obviously triglyceride is by far the most sensitive to nutritional change,

00:18:41.080 LDL receptor, probably the most genetically preset, that there are ways to tweak these things and

00:18:46.840 certainly drugs tweak them. So we've got lots of ways to do that. But this is an important thing

00:18:50.640 to know. I mean, the four lipoproteins that in approximately this order are important is Lp,

00:18:56.580 little a, L-D-L-P, small LDL-P, the subset of LDL that are below some cutoff, typically about 20

00:19:04.580 nanometers. And then we don't have a way to measure something called the VLDL remnant. So we use the

00:19:11.180 poor man's proxy as I look at VLDL cholesterol, which you take the non-HDL cholesterol and subtract

00:19:18.300 the LDL cholesterol, which you get off a standard lipid panel. That's especially helpful if at least

00:19:23.320 the LDL is measured directly. But then of course you're often compromising and getting an indirect

00:19:28.860 measure of the non-HDL. So, but that probably is a better proxy than taking triglyceride and dividing

00:19:34.080 by five, which is the other poor man's way to get a VLDLC. And I like to see that number less than 15

00:19:40.740 milligrams per deciliter. Did you just find a utility for total cholesterol test? I have zero

00:19:46.960 utility for total cholesterol. I think the only time a clinician should ever even pay attention to that

00:19:53.900 number is if you have a patient that you are concerned has FH, familial hypercholesterolemia,

00:19:59.380 and you're trying to get them approved for a PCSK9 inhibitor, then you will actually need to know

00:20:05.020 their total cholesterol and their LDL cholesterol because you will use cutoffs, typically total

00:20:10.720 cholesterol more than 350, LDL cholesterol more than 250 milligrams per deciliter is your cutoff. But

00:20:15.360 I don't pay attention to LDL cholesterol. I don't pay attention to total cholesterol and I pay minimal

00:20:21.520 attention to HDL cholesterol. I'm more interested in the ratio of triglyceride to HDL cholesterol.

00:20:26.880 But as we know now, increasing HDL cholesterol pharmacologically does not seem to have any

00:20:34.200 benefit. I'm not even convinced increasing it dietarily does. I think it just goes along for

00:20:38.960 the ride. In other words, I think that the things in a person's nutrition that increase their HDL

00:20:43.380 are benefiting, but not because of the HDL. The HDL-C is going up as a result of it.

00:20:50.260 So I guess after all that rambling, I've basically said three things, which is LP little a, ApoE,

00:20:57.300 LDL-P. I think everybody should encounter an oral glucose tolerance test and in particular one that

00:21:05.380 uses insulin as well as glucose. So not uses insulin, but measures insulin. So you would take a fasting

00:21:11.580 glucose insulin level. You would consume a standardized amount of glucose. Typically it's recommended to use

00:21:18.480 75 or 100 grams of liquid glucose called glucola. We do that for most of our patients. However,

00:21:26.460 I am now on occasion using normal glucose to challenge them. So a hundred grams of glucose in

00:21:34.000 the form of rice or potatoes, because I do think there's a subset of people who you're getting misleading

00:21:40.140 responses from when you're using liquid glucose, which is actually quite unnatural.

00:21:44.680 You don't consume glucola regularly? I mean, I, I didn't look in your fridge, but

00:21:49.340 you know, I've got six bottles back there, but I save that only for the special occasions,

00:21:54.140 like along with the other alcohols that I like. Now the shit is horrible. Taking enough of those

00:22:00.260 glucose tolerance tests. In fact, I'll probably never do one again. I'll probably from now on only do them

00:22:04.500 with, you know, rice or potatoes or something like that. Is that complicated to, to do the OGTT

00:22:09.700 with insulin? Or is that something that most, well, you know, it's interesting because I do see some

00:22:13.940 stuff on Twitter about, Hey, why do I need to go to my doctor to do that? I can just do it at home

00:22:18.200 and you can do it at home with the glucose response because you know, we have portable glucometers,

00:22:23.140 uh, but insulin can't be measured easily. It's not a test you can do at home. And so it needs a laboratory.

00:22:29.220 And if you're not seeing the insulin, you're not knowing the answer. So if you fail a glucose

00:22:36.460 tolerance test on glucose levels, well, then you've really failed. And what do I define as a failure?

00:22:42.360 I want to see fasting glucose typically below 90. I want to see one hour postprandial below 120 to 130,

00:22:49.040 depending on the amount of muscle mass the person has. And I want to see two hour glucose below 100.

00:22:53.980 In other words, I have much more rigorous standards than the laboratory form would show.

00:23:00.020 And you can be there and still have hyperinsulinemia, especially postprandial. Usually a person there

00:23:05.960 will not have hyperinsulinemia when fasting, but it's not uncommon. In fact, I'm seeing a patient

00:23:10.820 tomorrow. I was just looking over his labs today and he's great fasting glucose. Fasting insulin is below

00:23:17.420 six, which is my target at one hour. His glucose is like one 14. Great. But his insulin is 56.

00:23:24.980 And at two hours, he's fine below 100 and his insulin is below 20. So what's, what is the

00:23:30.640 implication there of this guy? Who's got basically only one X on his record, which is his one hour

00:23:36.180 insulin is 56. Well, that's, you know, as Joseph Kraft describes that that's diabetes in situ.

00:23:41.500 So that is postprandial hyperinsulinemia, which is a harbinger to insulin resistance. And look,

00:23:46.700 he might be five years away from being insulin resistant, but that's exactly the time I'd like to be

00:23:51.440 able to, to intervene. And so this is one of those tests where, yeah, it would be a lot easier if we

00:23:56.320 could just do it at home with our glucometers, but I think it is worth the hassle of doing it and

00:24:00.520 getting the, the actual insulin data. Boy, what else do I like to see? I've already got pretty heavy

00:24:06.500 focus on the cardiovascular. So I'll try to avoid any other cardiovascular stuff. Although I obviously

00:24:12.200 a C-reactive protein, a homocysteine or an oxidized LDL or an oxidized phospholipid are really,

00:24:19.320 really helpful. But I think since we're only going for five, probably ALT, which I alluded to earlier.

00:24:27.440 I think today we're just seeing so much fatty liver disease. And again, the labs, which are basically

00:24:34.980 showing you plus or minus two standard deviations have just seen an upward drift of this over decades.

00:24:41.020 And I was actually just talking about this with Rob Lustig a while ago on another podcast, which

00:24:45.660 I don't know what order we're going to release these things, but that'll either have already

00:24:49.720 come out or be coming out. But we were talking about how we both sort of share this point of

00:24:53.920 view, which is we just kind of ignore the laboratory references on, on many of these things. And for ALT

00:24:59.280 on our lab up to 42 is normal. If I see a patient walking around at 38, I'm highly alarmed.

00:25:06.380 You made a great point about that too. I snuck in a listen to that podcast.

00:25:11.040 Sneaking in listens on the podcast already.

00:25:14.200 Membership has its benefits. The ALT, so 42, I think you said is, that's considered normal today,

00:25:20.080 but 30, 40, 50 years ago, that was not considered normal.

00:25:24.320 That's right.

00:25:24.840 Why?

00:25:25.620 I mean, I think Rob would argue, and I would agree that as we've seen an increase in fructose

00:25:30.440 consumption, it's driving a greater and greater prevalence of NAFLD. This was a condition that

00:25:35.620 wasn't even recognized 20 years ago. If the last data I looked at are any indication by 2025,

00:25:42.140 the combination of the success we've had treating hep C and the rampant rise in NAFLD means by 2025,

00:25:49.480 this will be the NASH, which is the sort of NASH, NAFLD to NASH to cirrhosis. That pathway will be the

00:25:55.580 leading indication for liver transplant in the United States, which is sort of hard to contemplate when,

00:26:00.900 when you realize that in the year 2000, less than 1% of liver transplants were for non-alcoholic fatty

00:26:06.660 liver disease.

00:26:07.180 And I think one of the things about the lab, the reference ranges, is that they're based on

00:26:12.800 the population mean. So 30 to 40 years ago, an ALT, a normal ALT would be actually considered lower

00:26:20.840 than 42. But because the national average is higher, when you look at a lab test, you're within

00:26:27.080 range, you may be at 42 and you're looking at it and saying, I want it below 20.

00:26:31.480 Yeah. The other thing I've seen enormous drift on, even just in my very, very brief career on a

00:26:38.140 relative basis is estradiol levels in men. I mean, I've seen two upward shifts in the range at the same

00:26:46.480 lab over eight years. So men are becoming more and more and more estrogenized. And there are lots of

00:26:53.040 reasons for that, which we'll probably talk about on another podcast. So those are my, I can't even

00:26:57.660 remember. I lost track how many labs I recommended, but I think the spirit of the question was, if you,

00:27:01.720 if you're going to be a minimalist, what are you going to do?

00:27:03.880 You got five in there. Definitely. Does that cover just in general, or does that also cover

00:27:08.340 the markers for longevity? Do you want to get into like, if you could actually measure some things

00:27:12.500 for longevity, but you really can't in a lab test that you would want to look at?

00:27:16.820 So if we're talking longevity purely in terms of lifespan, how long, you know, looking at someone's

00:27:21.780 blood, can you get a sense of how long until they're going to die? The way to think about that.

00:27:28.020 So what you're not going to get on a standard blood test is any of the longevity genes. I mean,

00:27:32.840 you can get some of them, but you certainly ApoE would be one of the longevity genes. LP little a

00:27:38.160 would be a longevity gene in inverse. So the lower your LP little a, the greater your chance of

00:27:42.840 cardiovascular mortality. So the way I really think about longevity in blood is the three things that

00:27:49.120 you're looking for in blood disease wise are what is this person's risk of atherosclerotic disease?

00:27:54.180 So heart disease or stroke, what is this person's risk of cancer? What is this person's risk of

00:27:58.020 neurodegenerative disease? So as you march down those things, you would say, well,

00:28:02.600 cardiovascular disease, largely driven by three things, lipoproteins, inflammation,

00:28:07.480 endothelial dysfunction. How much of that can we see in blood? Actually a lot. On the lipoprotein side,

00:28:13.080 we can see most of what we want, which is the LP little a, the LDL, the small LDL, I'm talking

00:28:18.920 particle number, not cholesterol, and the VLDL as alluded to. On the inflammation side, we can see

00:28:24.880 specific and nonspecific markers of inflammation. So on the nonspecific side, we can see things like

00:28:29.080 fibrinogen, C-reactive protein. On the specific side, you can see things like ox LDL, LPPLA2,

00:28:36.580 ox phospholipid, those things. Very helpful. Endothelial health is the hardest thing to see,

00:28:41.920 but I include insulin here because I think that insulin is in and of itself actually toxic at high

00:28:47.400 levels to the endothelium. And James O'Keefe just recently was on a paper that looked at

00:28:52.640 cardiovascular health in patients with type 1 diabetes so that they were able to actually use

00:28:57.100 the insulin doses that people were using as a way to actually assess the impact on the,

00:29:03.340 I can't remember if it was myocardium or endothelium. You can look at things like homocysteine. We also

00:29:08.340 look at something called asymmetric dimethyl arginine or ADMA and SDMA, which are inhibitors

00:29:13.340 of nitric oxide synthase. So the way I tell patients is the younger you are, the more your blood tells me

00:29:19.600 about your risk of cardiovascular disease. So a 40-year-old person who otherwise doesn't have

00:29:24.680 like some dramatic, you know, LP little a through the roof or something crazy, the blood tells me

00:29:30.140 probably 80, 85% of what I need to know. The older a patient gets, the more I would probably rely on

00:29:36.160 things like CT angiograms or even, usually by the time they're older, a calcium score becomes less

00:29:41.280 relevant. Calcium score can be somewhat helpful in a younger patient though. But it's, you know,

00:29:47.520 the latest study I saw, which actually just was an editorial that came out two days ago based on a

00:29:51.560 study in one of the atherosclerosis journals, was, you know, looking at 50% of patients that had

00:29:56.440 events had them at the site of non-calcified lesions. Not a huge vote of confidence for

00:30:03.140 why a low calcium score is that helpful. On the cancer side, I think that's really, frankly,

00:30:09.520 where blood gives us the least insight. You know, until companies like Grail have fully functioning

00:30:15.480 liquid biopsies where you're looking at, I think Grail's probably looking mostly at RNA and DNA.

00:30:22.620 Other companies have looked at circulating proteins. But until these liquid biopsies are there, we can't,

00:30:27.820 we don't really have much insight into it. Also, virtually every cancer is a result of a somatic

00:30:33.620 mutation, not a germline mutation. So knowing your genotype doesn't really help outside of a few

00:30:40.320 outlier things like BRCA or Lynch. So it, you know, in cancer, it really comes down to understanding

00:30:46.660 inflammation, which we've already addressed and metabolic health, which again was also part of the

00:30:51.240 cardiovascular stuff, though I didn't go into it. But so for me, minimizing hyperinsulinemia becomes

00:30:56.240 very important. And I suspect we'll probably have an entire discussion on the role of IGF in cancer

00:31:01.260 and IGF BP3, because I think it's actually quite controversial. But that can also provide some

00:31:06.360 insight. And then Alzheimer's disease actually, I think, is more closely related to cardiovascular

00:31:11.660 disease in terms of risk stratification. So first of all, knowing the patient's APOE immediately gives

00:31:17.260 me a bucket to put them in, which is, you know, low, medium, high risk. I mean, that's, I don't call it

00:31:22.540 that, but that's sort of how you can think about it. And then you look at the other dimensions of it,

00:31:27.440 which is there's a vascular component to that disease. And that basically proxies what you're

00:31:32.960 seeing in cardiovascular risk. So the more you can improve the cardio metabolic profile,

00:31:37.500 the more you can improve that. Then there's the metabolic component period, which is kind of like

00:31:42.200 the glucose utilization part. And that sort of reverts back into all the metabolic stuff you see in

00:31:47.140 cancer. There's a, an entire thing around toxins, which unfortunately is probably the one that we

00:31:52.520 have the least insight into measuring. And, you know, for very high risk patients, we do refer them

00:31:57.720 to Richard Isaacson's clinic at Cornell, which is a dedicated high risk clinic. And certainly there,

00:32:04.000 if the cognitive tests warrants it, they'll do lumbar punctures and start to look at CSF for other

00:32:09.240 markers. But obviously we don't do that. And unfortunately we don't have too many patients that are

00:32:15.040 cross-modinating over there. I don't want to harp on this one, but I thought it was a good point that

00:32:20.000 you brought up. You touched upon with the insulin and that some people will get a, they'll get their

00:32:24.420 glucose tested, you know, every year. And they say, my glucose is fine. It's, it's 82 or whatever it is.

00:32:31.060 And you know, if they assume that their insulin's fine too, because they're clearing their blood sugar

00:32:36.040 and it's 82, can you explain just why you're not, I mean, you're literally not looking at insulin,

00:32:42.240 but insulin could be elevated and you wouldn't know it. Yeah. And usually the person walking

00:32:46.480 around with a fasting glucose of 82 probably doesn't have a very high fasting insulin. It's

00:32:54.440 the postprandial stuff you worry about. And then like, this gets more complicated because you then

00:32:57.960 have to worry about, are you being misled by the test? So I'm sure many people are listening to this

00:33:03.280 who are already aware of this, but I'm sure enough people aren't that it's worth the time. But if you

00:33:08.140 take somebody who's on a ketogenic diet or a very carbohydrate restricted diet, it's more common

00:33:13.560 than not when you do an oral glucose tolerance test on them, that they will have this paroxysmal,

00:33:21.560 very elevated glucose, very elevated insulin after being challenged. So they'll have a low fasting

00:33:27.100 glucose, low fasting insulin, and then you give them the glucola and their glucose and insulin are sky

00:33:33.040 high. I think I may have told the story once on a podcast about a guy I knew who had gone on a

00:33:40.160 low carb diet and everything had gone great and blah, blah, blah. He lost a bunch of weight and got

00:33:44.080 healthier and everything was amazing. And then his brother who had type one diabetes needed a kidney

00:33:48.200 transplant and he was a match. So they said, well, all right, we just got to test you and make sure

00:33:52.120 you're not diabetic or anything before we take one of your kidneys. They did an OGTT and he quote unquote

00:33:57.660 failed. And he called me in distress and he was like, oh my God, I can't even give my brother a kidney.

00:34:02.060 And I've said, well, here's the thing. You got to have them repeat the test and just, you got to

00:34:07.100 refeed with 150 grams of carbohydrates, just eat 150 grams of rice, potatoes, whatever for about three

00:34:13.020 days leading up to the test. They repeated the test. Obviously everything was fine. The next time he

00:34:16.860 called me, he was leaving the hospital after the transplant, everything had gone well. The other

00:34:21.340 thing with fasting glucose, by the way, that's kind of useless is it's helpful if your fasting glucose is

00:34:26.140 150. There's clearly a problem, but I get patients that get, you know, very upset or

00:34:31.580 phosphorylated if their fasting glucose is 105. And I got to tell you, now that I wear a continuous glucose

00:34:37.260 monitor and I know my glucose 24 seven, the difference between a fasting glucose of 90 and 105 in the

00:34:44.180 morning is much more a function of my cortisol level than it is anything to do with my insulin

00:34:49.380 sensitivity or, you know, anything like that. So it's, you know, it's important to understand the

00:34:54.740 role that even stress can play on glucose. And that's why I think fasting glucose is

00:35:00.020 directionally interesting, but it's the, it's the insulin that gives you the, the, the more fine

00:35:04.880 tuned insight. Okay. This might be jumping around a little bit, but you talked about your continuous

00:35:10.480 glucose monitor. And I think a couple of people asked about that because they realized that you have

00:35:15.400 a CGM and you're not diabetic. It's usually when you have a CGM, people say, aren't you diabetic?

00:35:21.220 Cause it's what it's typically used for. So we could get into a, why do you, why do you wear the CGM?

00:35:27.480 And then probably a pretty nerdy game of would you rather, which is obviously not the glucose,

00:35:33.820 but let's say like an OGTT with insulin, would you rather see that in a patient? Or if a patient could

00:35:39.560 have the, you know, the Dexcom five or whatever the latest and greatest is, and you knew exactly what

00:35:44.760 they ate for like a month and you could follow those numbers. Where are you going to learn more

00:35:49.300 about that patient through one of those tests or the other? Uh, boy, that's a good question. I think

00:35:54.740 that to have CGM data on a patient and a lot of our patients don't want to wear a CGM, although I

00:36:00.480 think that's going to change with the Dexcom G6. So I, you know, I started my career using the G5. No,

00:36:07.540 um, you know, the G5 I love, but I could understand why if you didn't actually have type,

00:36:12.680 you know, diabetes, you know, that was a bit of a, a bit of a stretch because, you know,

00:36:16.980 you're, you're inserting this needle and it was, you know, it was just a bit more involved.

00:36:21.520 Plus it required calibration twice a day. Uh, then a company called Libre got bought by Abbott and

00:36:27.480 they had a no calibration one that got quite popular, but we've used it a lot and I find it

00:36:35.060 to be categorically useless. It's so inaccurate and you can't force a calibration. Uh, also it doesn't

00:36:41.800 have, you can't, it doesn't interact with your phone. So it's just like useless in that regard.

00:36:47.140 So do those both use a needle in the same place? The Libre is typically inserted on the back of the

00:36:53.260 arm and it's a, it was at the time, a much easier way to insert the new Dexcom G6, which I don't

00:36:59.780 think is out yet, but I've been lucky enough to have a prototype for a while. Uh, the, the,

00:37:04.700 the G6 inserts the same way as the Libre it's, it's, it's plug and play. It's trivial. It requires,

00:37:09.500 you don't even feel it going in. It's a much smaller needle goes in much faster. So you don't,

00:37:14.040 you're not, you're not the one responsible for the velocity at which it goes into you.

00:37:17.380 And it also doesn't require calibration though. You can, I, I still spot check mine once a day.

00:37:22.980 I've been blown away by the accuracy and its interface with the phone is second to none.

00:37:27.840 So it's just, uh, it's just, it's, it's amazing. I think in reality, if I had a month of CGM data

00:37:33.920 with accurate food information, that's probably more valuable to me than the OGTT,

00:37:37.940 even though I'm giving up insulin, meaning I'm not going to get to see the insulin, but

00:37:41.860 I also get to see, you know, a month of someone in their real environment eating the likelihood

00:37:47.580 that I'll miss in that entire month. Cause they're going to probably eat something really bad.

00:37:53.160 And if I can see how they're reacting to that, uh, you know, that's probably pretty good,

00:37:57.900 but look, it's still not a complete substitute for that hyperinsulinemia. So it's, it's, it's,

00:38:04.340 it's not perfect, but I also find that the CGM for me is one of the, it's along with the,

00:38:11.700 my sleep ring, it's the stickiest device I've ever used. Whereas any other wearable I've ever

00:38:17.920 used, it's like after two weeks, I don't want to wear it anymore. Cause I've already learned

00:38:21.260 what I need to learn. Like I know how many steps I take. Why do I care? So I've got this whole

00:38:25.420 theory around what wearables matter. You know, it's like, are you measuring something that matters?

00:38:29.900 I don't want a wearable. That's telling me something that's irrelevant clinically is the

00:38:34.560 device actually measuring what it claims to be measuring. Is it, am I able to get feedback in

00:38:39.540 real time? Cause that was the problem with the Libre is you couldn't get real time feedback,

00:38:44.020 you know, unless you were going to carry around this other device it came with. Whereas with the

00:38:49.040 Dexcom, you're getting real time feedback. And so as real time as exists, meaning when you eat

00:38:54.940 something, you don't see your glucose move at that moment. But I certainly know after a meal,

00:38:59.160 how that meal or the amount of exercise or the amount of stress I was under impacted things.

00:39:05.380 And then do I have an ability to sort of fix it? Do I have any control over the outcome?

00:39:10.500 So, you know, CGM for me has continues to this day, even though we're probably three years into

00:39:16.280 doing this stuff. I mean, it's, it's hard for me to imagine a day when I'm not going to want to

00:39:20.780 know my glucose every minute of every day. How much of those two things, particularly the CGM,

00:39:27.800 maybe the ring too. Cause you're, you're talking about a lot of things, probably sleep,

00:39:33.080 exercise, diet, et cetera. Are these things almost like accountability coaches that the idea that

00:39:40.360 you get this real time feedback of the stuff that you're eating, if you're going to eat some

00:39:44.280 crap, whatever it is, you know, that it's going to show up. Do you think that there's any of that

00:39:49.980 aspect to those things? For me, there definitely is, especially on the glucose ring. I had a buddy

00:39:55.380 stay here last night and like after we went out and grabbed dinner and then on the way home, he's

00:40:00.720 like, Oh, do you mind if we stop at the store? I want to get some stuff for the morning. And he,

00:40:03.840 you know, got a little box of granola. And so, you know, this morning, you know, get up to our thing

00:40:09.260 and he eats some of the granola, but left the box. And as he left, I'm like, God damn it. Like,

00:40:14.800 I love granola, but like it's candy. It's not, it's nice. Like, you know, so I just threw it out

00:40:20.720 immediately, like open the thing through the granola out and make sure I wouldn't eat it.

00:40:24.400 And in part, I think it's that I know that if I eat it, I have to look at my CGM, just go up and

00:40:29.040 it just pisses me off. So it's like, I'm not going to do it. And maybe if I didn't have that CGM,

00:40:34.060 I would have mainlined that whole box of granola. There's a question in here that I have to get to

00:40:37.740 because it might relate to this. It says, how do you, how do you think having children has changed you,

00:40:43.180 has changed you most? I often think of like, what's at the dinner table and what's left over

00:40:48.280 in terms of your, you know, if you want to call it willpower or food that's left over

00:40:52.380 that might come into play. I mean, I hate to blame my kids for anything, but I'm easily 10 pounds

00:40:59.360 heavier and 10 pounds fatter. Thanks to them. I think the biggest issue is the food environment,

00:41:06.120 you know, here in New York, I eat really well because you mean, you see my kitchen.

00:41:12.060 The worst thing I'm going to do. Yeah. Yeah. The worst thing I'm going to do is

00:41:16.340 have a little extra almonds tonight. Like there's just nothing bad to eat in here. And this is where

00:41:22.060 I'm at my weakest is when I'm, you know, in my place. And it's not to say I don't go out and eat

00:41:26.420 a burger and fries sometimes, because certainly New York offers more of amazing decadent food than

00:41:31.880 any place else. But I think we're most vulnerable in the environment that we eat most. And, you know,

00:41:37.780 for some people that's work, for some people that's home, whatever. And so I think that the

00:41:41.920 challenge of having kids, at least for me, is that you just have more kid food around and try as you

00:41:48.120 might to say, we're not going to have that kind of stuff in our house. I mean, look, I, I'm guessing

00:41:54.400 my kids eat better than most kids. You know, they don't have juice in the house, soda, like a couple

00:41:59.540 times a year. There's like, you know, some diet Coke after a birthday party or something. But, you know,

00:42:04.860 for the most part, it's pretty good. But there's still a bunch of crap. Like, you know, those

00:42:09.480 crackers, wheat thins. My son, who you know very well, he calls them wheat thins. And he freaking

00:42:16.740 loves those things. Like, it's all he wants to eat. And he comes home from daycare and he's like,

00:42:21.960 Daddy, I want some wheat thins. And I'm like, what? Wheat thins. I don't know. What are you talking

00:42:27.320 about, Reese? Wheat thins. Oh, wheat thins. Got it. So, and I.

00:42:32.060 We not thins. We not, we not. And those things, I mean, I don't know if you've had one of those

00:42:35.940 in a while. Yes, I have. They are freaking awesome. Yeah. They must be just, they're so,

00:42:40.520 I don't remember them being that sweet when I was a kid. The texture too. Yeah. I remember,

00:42:45.220 yes, there was a period. I would stack them up, I think, too. Maybe stack up a couple of them.

00:42:48.960 Yeah. Oh, yeah, yeah. No. You don't eat those things one at a time. I feel like Will Ferrell in,

00:42:56.060 what was that hilarious movie? Old school. Old school. It just feels so good when they just hit

00:43:00.540 your lips. And then the other thing is there's just like a lot of the times, like if I'm, you

00:43:07.020 know, the kids will want homemade mac and cheese, which is like nowhere near as bad as the crap you

00:43:11.680 get out of a box. But look, it's still mac and cheese. And if they don't finish it, I still have

00:43:16.700 this immigrant mentality I grew up with, which is like, you don't throw food out, which is horrible.

00:43:22.860 But I was really raised like that was so instilled in me that you don't throw food out. So if my kids

00:43:28.420 don't eat their mac and cheese, I'm like, yeah, I got to eat it. And part of that's just I want to

00:43:33.780 eat it. But part of it's like, I really don't want to throw it out. So I'm just as likely to finish

00:43:38.620 off their salmon or steak as I am their mac and cheese. So I don't know. I mean, I think the

00:43:45.280 benefits of having kids have probably outweighed that, but that's definitely a drawback of having

00:43:49.420 kids. So before we leave the lab test, this is technically not a lab test, but I've heard you talk

00:43:55.160 about it a lot. And it's something that people probably could do and it might be a good exercise

00:43:59.220 for them. And that is family history. It can tell you a lot about your risk, maybe more so than some

00:44:06.600 markers. Can you talk about the importance of that a little bit? Yeah, I think it's I think it's

00:44:11.440 certainly more important than doing a whole genome sequence. So I've had a number of patients. I mean,

00:44:16.980 at least half my patients over the last few years have have either done a whole sequence or at the very

00:44:21.820 least done, you know, something like 23andMe and we run that through Prometheus. And I'm trying to

00:44:28.200 think of a single time when anything in there altered our treatment plan beyond what we already

00:44:36.520 knew. Maybe the odd patient that shows up with a TOM40 mutation who was otherwise an APO33 that you

00:44:42.940 think, okay, you're probably a little higher risk than we thought for Alzheimer's. So maybe that's one

00:44:48.000 exception. You know, we get some insights into caffeine metabolism, but we almost always know

00:44:52.560 the answer before we, you know, we look for it just based on what they tell us clinically. But the

00:44:57.620 family history is incredible. And a lot of the times you can see things in family history, like

00:45:02.400 you can often spot an elevated LP little a before you get the bloods back. Because usually I've done a

00:45:07.720 history and a physical on a patient before I get their first blood test back. And it's not uncommon

00:45:12.420 for me to see just a violent streak of heart disease in a family and be like, okay, you're going

00:45:18.820 to have an elevated LP little a. There's no two ways about it. And sure enough, they come back and

00:45:22.840 it's high. And you could see that their dad had it, their dad's mom had it, their dad's mom's mom had

00:45:27.500 it. And you just sort of, because it's a co-dominant inherited gene. So you can see how it rattled through

00:45:32.100 the family. Certainly also gives you a great insight into cancer and dementia as well. Less, I mean,

00:45:39.080 I think dementia is harder because obviously the further you go back, the less long people were

00:45:45.820 living. But as a general rule, we really look for the mosaic and pattern of a person's predicted

00:45:54.740 mortality based on their genes. And things will skew it. Your parents smoked and you don't smoke and

00:46:00.480 they're getting disease all over the place. It's hard to infer there. I have a patient whose mom just

00:46:08.340 died very recently from lung cancer, but it was non-small cell lung cancer. So, you know,

00:46:14.440 what do you do with that? She was a heavy smoker. He's not. Does that really increase his risk? I

00:46:18.680 mean, as you know, we do a staggering amount of work on cancer screening in our patients. And you've,

00:46:24.440 you basically are the guy who runs our model on that. And it's actually a cancer by cancer issue.

00:46:30.760 There are some cancers in which, you know, a first degree relative that has it, it's a big,

00:46:35.140 you know, and sometimes it's not obvious, like the first degree relative that has bladder cancer

00:46:38.860 and what's the relationship to you having prostate cancer or vice versa. So when we do the cancer

00:46:44.000 screening in particular, we have the patients go back and do an even more detailed double click on

00:46:49.560 their family history of cancer. So yeah, I think family history is probably one of the more important

00:46:56.280 things we get out of the history on the patient. MD selection. I think you've received this question

00:47:03.520 more than once. How do I find a good doctor? So what is the best way to find a really good primary

00:47:09.940 care physician? Are there specific telltale questions labs I should bring up with a prospective

00:47:15.360 PCP? I think we covered that, but also to see if they've picked up a medical journal in the last 20

00:47:20.400 years. You know, I sort of actually had this discussion with a patient on Monday who's looking

00:47:26.660 for a concierge, you know, primary care physician, since I'm not a PCP and I, many patients come to me

00:47:32.300 already with a PCP, but sometimes they don't and they want to have this question. So, you know,

00:47:37.060 I kind of walked him through my mental model, which is there's no one size fits all here. You just have

00:47:44.240 to decide what it is you need and want. So I think about availability, affability, ability,

00:47:53.440 and advocacy as sort of the four broad pillars that you're looking for in a physician.

00:47:58.960 And it's pretty much impossible that you'd find all of those in the same person.

00:48:04.660 So what do I mean by those things? So advocacy is the physician who's connected and knows how to

00:48:11.100 help you navigate through a storm. When you need to go get a colonoscopy, they know the absolute best

00:48:16.500 endoscopist. And if God forbid, like something comes back with a positive finding, they know exactly

00:48:21.800 the right surgeon and boom, boom, boom. And not only do they have the Rolodex, but they know how to help

00:48:26.620 you get through that. Uh, they will be your, you know, your advocate in the system. I personally

00:48:32.960 think that's very important. I think many people aren't actually thinking of that, but it's important

00:48:37.280 to, to sort of ask a doctor explicitly and directly about that. Ability to me is obviously, I just think

00:48:45.140 that that's the single most important thing. I mean, in the end, yeah, bedside manner is great.

00:48:49.880 Affability is important, but I'll never take affability over ability. You'd want both. They're not

00:48:54.900 mutually exclusive, but don't be confused. Can don't be confused by affability at the expense of

00:48:59.480 ability. So we'll come back to how, maybe how you can assess ability, but that that's important.

00:49:05.360 Affability is like, do you get along with this person? And I think you should be able to get

00:49:09.000 along with your doctor. I mean, I think the days of going to the doctor who talks down to you and

00:49:13.660 is basically preaching a bunch of commandments, you know, it just doesn't make any sense. Like you just

00:49:18.700 don't want those kinds of people around because yeah, in the end they might be the expert,

00:49:22.500 but if they can't bring you along, then the relationship probably doesn't fit. And if I,

00:49:26.500 if I have a patient in which I feel like I can't bring them along or I don't connect with them, I

00:49:29.900 certainly say to them, look, maybe this isn't working, you know? Uh, and in the end you maybe

00:49:34.400 need somebody different from me who can communicate in a way that you like to be communicated with.

00:49:40.460 Availability is basically, or access is like, are you looking for someone that you can call 24 seven?

00:49:45.940 And that's when people are looking for concierge docs, that's generally what they're looking for.

00:49:50.060 There are lots of non-concierge docs though, that still have, and within the world of concierge,

00:49:55.700 look, you've got like the $30,000 a year concierge guys and you've got the $3,000 concierge guys. And

00:50:00.820 so you also have to be able to think about, okay, well within that, like what's the difference

00:50:04.880 between those two? What's worth $27,000 more per year? If, if that's the, and those are literally

00:50:10.780 like, that's probably the range that I see in New York for concierge PCP. But I guess the person

00:50:16.960 asking this question is probably thinking mostly about ability. I think, you know, the, the question

00:50:21.560 included something about, have they read a medical journal in the last 20 years? I mean, that's a

00:50:25.660 good question because so much of what we learn in medical school is pretty much irrelevant by the

00:50:31.220 time we're practicing and the lag between when something becomes a finding and when it becomes

00:50:38.800 mainstream or obvious enough that everybody's doing it. You know, I've seen that number estimated at

00:50:45.320 anywhere from 12 to 20 years. So yeah, it seems like a pretty inefficient system. So I think there

00:50:53.060 you just want to talk to your doctor and say, look, how, how busy are you clinically? How much time do

00:50:58.880 you spend reading literature? And again, I wouldn't use buzzwords like evidence. Do you practice

00:51:04.080 evidence-based medicine? Cause what doctor is going to say no to that question? Like it's sort of a

00:51:08.120 silly question. It's, you know, it's like, um, so it's mostly just trying to inquire about the

00:51:14.100 curiosity of the person, their passion around learning. Cause I think in many ways, if you're

00:51:20.420 not learning quite a bit as a doctor, you're probably not practicing great medicine. If you're

00:51:26.180 not sort of trying to get smarter on diagnostics or, you know, advancements in the field, then I,

00:51:32.760 you're probably stagnant. And it's not to say that a doctor who's stagnant can't do great work on

00:51:39.400 certain things, but for most people, they don't want to have like six doctors in their life. You

00:51:44.240 know, they sort of, you want to go to one person. So I think that's how I sort of think about that.

00:51:48.920 Unfortunately, I'm not really a fan of a lot of the labels that people put on like, well, I,

00:51:54.820 you know, I practice functional medicine or I've, I'm part of, you know, this organization or that

00:51:58.840 organization. I just, I don't know. I think in the end, you got to just evaluate the person

00:52:02.480 individually regardless of those, those features. And, um, I don't know. I don't know if that

00:52:08.280 answers the question, but I think so. I think one of the things that I was thinking about is people

00:52:13.600 will ask, people will be relatively specific and they'll say, I live in Boise, Idaho. Do you know

00:52:18.680 a good doctor there? You may or may not know a good doctor there. However, it brings, it probably

00:52:24.680 brings up the point that if you can get a referral from somebody that you really respect and think is a

00:52:28.920 great doctor and knows their stuff that a referral probably would be pretty valuable there too as

00:52:34.560 well. But it's very hard probably to refer somebody if you're in your own practice as a doctor to really

00:52:40.000 vouch for somebody else across the country. Yeah. I mean, my, my, my ability to do that is, is if it's,

00:52:45.360 if it's going to happen, it's going to be by luck. It's going to be, I already have a patient there

00:52:49.280 and they've got a doc who I've entered. Like I, you know, I'm a patient in Seattle who's got a,

00:52:54.360 an amazing PCP up there who I won't name now or else he'll get inundated with a million people.

00:52:59.620 But frankly, I think his practice is probably full, but every time I've had a patient move up

00:53:05.380 to Seattle, it's like, that's going to be your doctor. Cause the guy's like, he is the epitome

00:53:11.100 of what a great PCP is. And I, I love reading his notes. I just, I love interacting with him and I love

00:53:18.640 that, you know, we compliment each other. In other words, there's a whole bunch of things that I do

00:53:22.980 that, you know, look, he sort of knows a little bit about, but he wants to know much more about

00:53:27.440 lipidology and cancer screening and, you know, some of the exercise stuff we're doing. But then

00:53:31.820 there's a bunch of stuff he does that I, like his knowledge of, you know, when the patients travel

00:53:36.300 to this part of the country, you got to be aware of this particular parasite that can show up and

00:53:40.600 here's how we're going to vaccinate you against this. And here's how we're going to, you know,

00:53:43.860 you were in that cave in Texas. Well, you're very susceptible to this kind of thing. And, and just,

00:53:48.340 you know, someone's got like a, a, an HSV flare and like, he knows all of the tricks. And so

00:53:54.500 that's probably the easiest way for me to refer people is that I've worked with the doc directly.

00:53:59.520 Going back to the point though, I don't think people should be afraid of this process taking

00:54:04.240 a while. In other words, if you, if you go down the path and you find somebody and you think this

00:54:08.480 is going to be my doc and you know, six months in, you don't like him or her do it again, keep doing

00:54:13.960 it, keep doing it. And a lot of the questions you ask, the doctor's reaction to those questions

00:54:19.440 is probably a litmus test. So if, if you sense that a doctor is put off by a curious patient,

00:54:25.340 who's showing up wanting to be actively involved in their health, well, then I, you don't want that

00:54:30.520 doctor. You don't want someone who's intimidated or put off by your interest and obsession in this

00:54:37.340 stuff as a patient. Segway into racing. You got a number of questions on racing. This one

00:54:45.860 stood out to me. I'll just ask it first. What was the hardest thing for you to learn when you're

00:54:51.220 becoming a driver? I suspect this is racing, not when you got your driver's license, but you could

00:54:57.240 answer that one too. Parallel park. No, I think the hardest thing is something that I still struggle

00:55:04.180 with is, um, so, so when you think about driving, like what are the sort of elements of it? The

00:55:09.920 first, I guess, is sort of understanding conceptually what's happening. You don't have that many inputs

00:55:15.820 when you stop to think about it. You have throttle, you have brake, you have steering and you have

00:55:21.920 shifting. So, you know, you have a clutch and a, and a, and a, and a gearbox. Those are your inputs.

00:55:28.180 Those are your tactics. You go up and down on those things. Furthermore, you only have four

00:55:33.020 contact points. You have four tires that touch the surface and everything else is in service of those

00:55:42.420 things. So, and then also in the spirit of fours, there are basically four things that determine how

00:55:48.120 fast you're going to go, which is the tires because they're the contact point, the engine,

00:55:53.120 which provides the power, the chassis, which includes everything from the stiffness of the vehicle

00:55:58.960 to its aerodynamics and its downforce. And then the driver. So you, as the driver, make up one

00:56:05.100 component of those four things that determines the outcome. You have these four contact points as the

00:56:10.280 tires, and you basically have four inputs. So I think the first thing that one has to learn is vision.

00:56:17.460 Like you have to understand, well, I guess the line slash vision I put together. So there's a,

00:56:22.900 there's obviously a line that a driver takes. If you're watching a race on TV, you're noticing that

00:56:27.660 all of the drivers are driving in the exact same place unless they're overtaking another driver,

00:56:32.280 but there's a optimized fastest way to go around any race course. And for every circuit that I would

00:56:40.940 drive either, either real or in the simulator, I know the line like inside, like I know exactly where

00:56:47.780 the car needs to be at every moment in time. And I think for some people that takes longer. For me,

00:56:53.900 that was one of the few things that didn't take long because maybe because I'd already

00:56:57.280 ridden a bike so much, a bicycle. And I, you know, in time trialing where you're on these

00:57:02.700 every second counts, like you learn exactly what, where the apex of a corner is, how to take a corner,

00:57:10.060 all of those things. So I think that came to me pretty easily in driving. You have two types of

00:57:14.920 steering issues when you're going around a corner. Obviously cornering is what makes driving hard.

00:57:19.580 It's easy to drive, uh, in a straight line really fast. It's hard to drive around a corner really

00:57:24.240 fast. And the two things that tend to go wrong are understeer and oversteer. So understeer is when

00:57:30.540 the steering wheel is turning more than the wheels are turning. So that means that if you're trying to

00:57:38.500 turn to a corner of the, around the right, your wheels are pointing in a direction that is turning

00:57:45.440 you to the right, but you're drifting to the left. So that's called understeer. You are steering less

00:57:50.700 than you would like to. That is a relatively easy problem to correct. And it's also a relatively easy

00:57:57.700 problem to see because where you're going is not where you want to be going. And that is almost always

00:58:03.980 the result of too much speed that you, and again, for every situation you have to decide, are you

00:58:08.680 backing off the throttle? If you're on throttle, you're actually applying brake, et cetera.

00:58:13.560 Oversteer is the opposite of that. Oversteer is the back end of the car is starting to come out

00:58:19.160 from behind you faster than you want it to. So that means the car is now going to turn faster than the

00:58:27.420 rate at which you've asked the wheels, the front wheels to turn. Now I think learning to correct

00:58:34.020 an oversteer is for me the greatest learning curve because it's not something for which the initial

00:58:43.600 cue is visual. It's actually something you feel. You feel oversteer in your butt because it's basically

00:58:51.060 your butt and the seat are starting to go in a direction that you don't want to go. And there's a

00:58:57.120 well-understood way to correct an oversteer, but it's well understood conceptually. It's not

00:59:01.260 necessarily intuitive. The first step of correcting an oversteer is intuitive, which is changing the

00:59:06.340 angle of the wheel, the front of the car. It's the pause and the correction that comes after that is,

00:59:12.700 it's like, and again, I'm positive that there are many drivers out there for whom this was a trivial

00:59:17.860 exercise to learn, but for me it was not. And in fact, one of the things that my coach had me do

00:59:23.560 was he was like, look, you just got to get comfortable going sideways. And so he sent me

00:59:27.920 off to sprint car school. You know, sprint cars are those huge wheels in the back, little wheels in

00:59:32.920 the front, very small cars in terms of weight and staggeringly overpowered, but you're basically

00:59:39.200 driving that car sideways. You're drifting the whole way. I was like, Hey, should I go to drift

00:59:43.600 school? And he's like, no, no, no, go sprint car. I mean, that's, that's where you'll really learn

00:59:47.200 this stuff. I think the other thing that was hard to learn, although I'm so much better at it now that

00:59:53.220 it's, I mean, not to say I'm good at it, but I'm so much better than where I started is understanding

00:59:59.720 how to modulate, you know, a one out of 10 response on the throttle and the brake. When,

01:00:04.900 when you're driving in the street, you're not really thinking of that stuff. You're on the gas,

01:00:09.160 you're not on the gas, you're on the brake, you're not on the brake, but in a race car, even how you come

01:00:13.720 off the brake pedal. You know, if you're at a five out of 10 brake, do you go five, four, three, two,

01:00:19.780 one or five, three, one off. And those will produce at, especially at high speeds and with turns that

01:00:28.540 will produce a very different sensation. In one of those, you're flipping the car around and the other

01:00:33.460 one you're driving quickly through the line. And so learning how to modulate throttle and brake

01:00:39.920 pressure and making those as smooth and elegant as possible, you know, that, that took some time.

01:00:46.700 It sounds like playing an instrument. Not that I play an instrument, but if I were to play an

01:00:51.140 instrument, well, you'd probably have to know those things. Yeah. I don't play an instrument either,

01:00:55.440 so I can't speak to it, but, uh, so on the, on the oversteer, just because I'm curious,

01:01:00.940 I always think of left turns as a NASCAR, maybe just in my head when I'm thinking of turning.

01:01:06.680 So if you're doing the oversteer and your, your butt sticking out to the backside is moving out

01:01:11.760 to the right. So you're oversteering the, I mean, you're oversteering and you're moving too far to

01:01:16.300 the left. How do you correct that? So the first thing you do to correct an oversteer,

01:01:21.300 if you're in that situation is you actually jerk the steering wheel to the right to flip the front of

01:01:26.820 the car. And then you're basically going to pause for a moment and let it correct and then come back

01:01:32.780 onto throttle and pick it around. And so when you watch, look at, you know, there's a guy named

01:01:38.460 Chris Harris. There's lots of guys online that, you know, are great to watch, but Chris Harris is

01:01:42.060 one of my favorite drivers and he's like a drifting machine. I mean, this guy, he's really got it down,

01:01:47.440 but if you want to be able to drift a car, you basically have to put the car into an oversteer

01:01:53.080 and then hold it there for a long period of time. So one of my favorite videos is Chris Harris

01:02:00.300 drifting one of the nine 11 GT three nine nine one. So of course maybe we'll find the video and link it

01:02:07.580 to people, but it's a, he's test driving like the first generation of the GT three RS. This is probably

01:02:14.240 like 2015. And he's, I think he's at the Porsche circuit and there's this one turn where it's like one

01:02:21.680 of the most beautiful examples of a controlled oversteer drifting around. And it's one of those

01:02:27.720 things when if you watch it and you're not a driver, they make it look really easy. When I watch it,

01:02:33.360 I'm just going, God damn it. How does he do that? Like, cause I'm actually watching the micro

01:02:38.180 adjustments of his hand and I'm like, he is so talented. I will spend the rest of my life trying

01:02:44.000 to become half that good. Speaking of talent, one of the questions is just comment on the reasons you

01:02:50.540 are a great fan of Senna. You know, I mean, I think Ayrton Senna is probably considered by many

01:02:56.960 people to be the greatest race car driver ever. He died of course, quite tragically and quite visibly

01:03:04.520 on May 1st, 1994 at Imola in Italy in an accident that is to this day still debated as to the cause of

01:03:13.580 it, though I have very strong point of view on what the cause of the accident was. You know,

01:03:19.080 I think on many levels, one, he was just so naturally gifted. I was talking, actually it was

01:03:24.200 one of my patients the other day and he was telling me a funny story about how he, I don't

01:03:31.280 remember the connection. It was like his girlfriend's brother or something like that, you know, grew up in

01:03:35.740 the UK, was, you know, like a guy like me, like not a, not a professional driver, but a guy who really

01:03:41.280 took his driving seriously and had spent years and years trying to hone this craft. And one day he's at a

01:03:46.880 track and he finally lets off his absolute fastest lap of his life in this car on this track. And this

01:03:55.140 was back in 1980 and there was this kid there and they were like, Hey, can this kid go take your car

01:04:00.080 around for a spin? You know, he's never been on this track before. He's never been in your car before.

01:04:04.680 And he said, yeah, okay, whatever. So the kid goes out and went six seconds faster than he had just gone

01:04:11.200 and smashed, like, which was then faster than anyone had ever driven any, you know, that, that

01:04:16.600 type of a car on that circuit. And of course the kid was Senna. So there's just this raw, natural

01:04:21.800 talent. Uh, the other thing I think is just this incredible passion. You know, there are some

01:04:27.320 drivers like Schumacher who you could, you could equally make a case would be as great a driver.

01:04:32.740 And certainly by number of championships will be the greatest driver, but you know, had a much less

01:04:38.900 emotional way of going about things. I also think just what Senna stood for both, you know, on and

01:04:46.220 off the track. I mean, I think many people were not even aware of how much he cared about Brazil and

01:04:53.120 the people of Brazil until after his death, when people realized how much of his enormous wealth he had

01:04:59.840 contributed to, you know, fighting poverty in Brazil. And to this day, the Senna foundation is

01:05:05.440 kind of a remarkable organization there. I'm constantly moved by the response that anyone

01:05:12.520 from Brazil has to Senna. Our nanny is Brazilian. And I don't even think she was alive when Senna was,

01:05:19.000 when Senna died. But I mean, she knows everything about Senna. We talk about Senna all day long.

01:05:24.180 My son's name is Ayrton. So, you know, she just loves taking care of little Aerie.

01:05:28.340 I was in an Uber two weeks ago up in San Francisco. And, you know, the guy had a Brazilian flag all

01:05:34.500 over the car and blah, blah, blah. And of course, we got talking and he started asking me about this.

01:05:39.460 And then five minutes into the discussion, he goes, wow, you're really a Senna fan. And I was like,

01:05:44.320 well, yeah. I mean, that's all we talked about the whole way to the airport. So, you know, that you

01:05:49.460 could still find, you know, something to talk about with so many people. It's sort of amazing. And I think

01:05:56.720 many people look back at the era that Senna raced as the golden era of Formula One, because it wasn't

01:06:03.140 just that you had Senna. It was that you had Prost, you had Mansell, you had Piquet. I mean, you had

01:06:08.800 amazing drivers in an era where the drivers mattered more than they matter today. And that's not to take

01:06:16.820 anything away from Hamilton or Vettel or, you know, any of the great drivers today. And those two are

01:06:22.840 amazing drivers. I think Lewis Hamilton is probably the best driver today. But the cars are so much

01:06:28.160 better today than back then. So much safer. They have so much more downforce. Back in the late 80s

01:06:35.140 and early 90s, I mean, you were basically riding on mechanical grip alone. And when you look at

01:06:41.700 videos of these guys driving, you know, there's just amazing things. And then, of course, there's like,

01:06:47.480 God, I think it was 93. There's this very famous lap at, I think it was at Donington where

01:06:54.940 Senna started in the four position, meaning so he was fourth on the grid. So didn't have a very

01:07:00.780 good qualifying. And by the end of the first lap, he was in first. That, that we should also link to

01:07:06.500 that. I remember you sent me that link. Yeah. That's like, you'll never see that again. That was

01:07:11.460 sort of considered the greatest lap in the history of motorsport. Of course, the other thing that I think

01:07:16.140 is amazing is his qualifying time in Monaco in 80, God, is it 89, maybe 88, where he qualified about

01:07:23.940 a second and a half faster than Prost. And Monaco is a short, fast circuit. On the longest circuit,

01:07:30.380 you could never see a second and a half difference when you see. So, you know, in racing, we measure

01:07:35.700 things on the qualifying lap. They're measured to a thousandth of a second for a reason. There's a

01:07:42.340 reason it's not to the 10th of a second, you know, because the difference between 49.47 and 49.49

01:07:50.140 is pretty big. And those would otherwise both be 49.5. But when you're qualifying ahead of a four-time

01:07:57.540 world champion, which Prost was, a second and a half faster, you're just playing a different game than

01:08:03.440 everybody else. You know, Senna won three world titles, although I will always maintain that he

01:08:10.320 won four because in 89, he was disqualified in the final race in Japan for reasons that I think are

01:08:18.400 completely political and completely bullshit. So as far as I'm concerned, his disqualification was

01:08:23.440 nonsense and Senna died as a four-time champion. I'm convinced had he not died in 94, he would have won

01:08:30.800 the world championship that year, no question, even though it was the Williams 15 car that they were

01:08:36.800 in was having trouble. But the fact that Graham Hill almost won, Damon Hill, the fact that Damon Hill

01:08:43.440 almost won that year as the number two driver tells me that Senna would have absolutely won and probably

01:08:47.880 would have been incredibly competitive for the next two years. So, you know, had Senna not died, I mean,

01:08:51.480 you know, he could have easily had those seven world championships that Schumacher had.

01:08:55.580 But yeah, he'll just forever sort of be my favorite. And I love like, I mean, if anyone hasn't,

01:09:01.460 if anyone's watching this and is even remotely interested in this stuff and they haven't seen

01:09:05.000 the documentary Senna, it's such a beautiful. I was going to ask if that would be the one that

01:09:08.720 you would recommend. Yeah. Yeah. It covers a lot of this. Yeah. Yeah. Yeah. For sure.

01:09:12.320 Another racing question. This is a simulator question. How does iRacing improve your real world

01:09:18.300 racing skills? And could you do more official races or races with fans? Also favorite car?

01:09:26.200 So iRacing is a software program, which you run in a simulator. You don't need a simulator to run it.

01:09:32.760 You could probably just run it off your PC and play with like, you know, toys, but in a simulator,

01:09:36.880 it's really designed for a simulator because of how high end it is. I think that iRacing is good for

01:09:43.600 every element of driving, but it does have a couple of drawbacks. The first is we were talking about

01:09:49.960 oversteer earlier. And you'll remember that I said that oversteer is not as visual as understeer.

01:09:55.580 And that oversteer is something you first feel. The simulator can't really capture that. So when

01:10:01.420 I'm in a car and I oversteer, it's much harder to correct in iRacing because I lose the warning.

01:10:10.340 I only know what's happening when I actually see that I'm spinning. So it's not that it can't be

01:10:16.280 corrected. It's just, it's, it's harder. So it throws your timing off a little bit and what your

01:10:20.600 correction looks like. Uh, the other thing that, you know, obviously a simulator doesn't do compared

01:10:25.540 to being in the real car is you don't have the same physiologic stress. So I probably have more

01:10:31.440 seat time at a course called Buttonwillow because it's relatively close, meaning it's only like four

01:10:37.580 hours away, but it's in Bakersfield. And I like to go in the summer because nobody else does likes to

01:10:44.240 go in the summer. I can't understand why. And it's hard. I mean, it's, it's, you know,

01:10:49.880 you're in a fire suit inside of a closed cockpit car when the temperature in the shade is 108 degrees

01:10:55.120 Fahrenheit. It's probably 130 in the car. You know, it's like the little stuff. Like what do you do when

01:11:00.300 you can't keep the sweat out of your eyes? What do you do when your core body temperature is two

01:11:04.960 degrees higher? And, and what do you do when the dust is blowing in and blah, blah, blah, like,

01:11:09.720 you know, so, so you can't, that's just, and to be able to concentrate through that takes practice

01:11:15.100 and you don't get that practice in the simulator though. I do like, I'll wear my helmet in the

01:11:19.260 simulator and do it in a room that's hot and try to like mimic some of that stuff where the simulator

01:11:25.080 is incredible is just the economics of it. You know, every day you're in a race car on a track,

01:11:32.560 it's thousands of dollars. You know, it's just, you know, unless you're incredibly wealthy, like it's,

01:11:36.960 it's cost prohibitive to really learn how to drive a car well in a car. So just like pilots spend most

01:11:43.140 of their time in simulators long before they're up in the air, it's the same thing. And so when I

01:11:47.620 want to learn a new car or learn a new circuit, I want to get a few hundred hours of that on the

01:11:53.160 simulator before I go there. And it makes the experience much richer. And if I don't have that

01:11:57.700 luxury, for example, Buttonwillow is not in iRacing. So the first time I drove Buttonwillow,

01:12:02.700 I ended up having to watch tens of hours of onboard film in, of drivers driving Buttonwillow.

01:12:10.520 And even that just couldn't prepare me for it the way driving in the simulator could.

01:12:15.180 As far as my favorite car in the simulator, it really depends on what I'm, what itch I'm trying

01:12:19.680 to scratch. If I'm trying to go as fast as possible, it's the Pro Mazda, which is not the

01:12:24.240 fastest car in there, but obviously formula cars are much faster than closed wheel cars.

01:12:28.860 And, you know, they, they do have a formula one car in there. I think they have the MP4 30.

01:12:33.620 It's just still too fast for me. So even though it's a faster car, the thing's outrageous. So

01:12:38.920 the, but the Pro Mazda, like I'm getting to the point where I can drive that car relatively close

01:12:43.160 to its limit, probably within one to 2% of its limit. As far as closed wheel cars, it depends like

01:12:49.840 relatively aggressive and not that difficult to drive closed wheel car in there, but it's,

01:12:54.420 it's amazing how fast it is, is the Ferrari 488 GTE. It's a beast. And I like the roof nine 11,

01:13:02.720 which is actually really hard to drive, but it's so freaking powerful. And it's like, that's a car

01:13:08.120 that will punish you, just punish you if you make a mistake. And there's something, you know,

01:13:13.640 if you're going to get punished, I'd rather get punished in the simulator. So it's, it's nice to

01:13:17.360 learn that. But honestly, like, you know, even driving a Miata in the simulator is still

01:13:21.800 a blast. Cars are just fun to drive. So there's one more question. It's related. It says,

01:13:27.920 uh, curious what your choice of daily driver is. It depends on what one's optimizing for,

01:13:33.160 I guess. I, uh, groceries. Yeah, exactly. If you're optimizing for groceries, for being able to like

01:13:39.360 pick up your kids, if you're being able to, you know, like I used to drive an E92 M3 and that was

01:13:44.480 amazing because it had such a bit, it had a big enough trunk that if I took both wheels off my bike,

01:13:48.540 I could put my bike in my trunk. And that was essential when I was like riding my bike a lot

01:13:53.440 because, you know, three times a week I'd be training at a remote location where I had to

01:13:58.000 take my bike. So, you know, to have a car where I could easily move my bike was, was a given,

01:14:03.100 you know, fortunately, if there's one thing that driving in a race car has done is it's made me

01:14:08.640 less of a knucklehead driving on the street. So I don't feel quite the need or the desire to drive

01:14:16.080 for speed. Yeah. I thought you were setting me up and they're going to high five top. You know,

01:14:23.560 they're filming a second top gun. I'm told miss on the top hit on the bottom. That's the only way to

01:14:27.420 do it. I, I, I, the word on the street is they're filming top gun too. I heard that. Yeah. Yeah. I

01:14:32.500 can't wait to see ice man. I love nine 11s. I think they are great. I think no car really combines

01:14:41.700 the practicality of you can drive this car every single day and it's really fun to drive. And so

01:14:47.640 it's like, I call it sort of a, a civilized beast. So you mentioned putting the bike in the trunk of

01:14:53.180 the car, which kind of gets to exercise. You've got a bunch of questions about your exercise and

01:14:58.200 exercise in general. So let's go with your exercise in terms of, uh, this is a question about open water

01:15:04.860 swimming. The question is knowing what you do now, how would your preparation for those long open

01:15:10.060 water swims have changed still as many hours in the water prior to a big event? Would your feeding

01:15:15.640 strategy be any different? Yeah, I probably would have still spent the same amount of time in the

01:15:19.960 water, but that's because I was not a natural swimmer. And, you know, I was still at a point where

01:15:26.580 even just basic stroke mechanics were not automatic. So, uh, you know, if you remember, I talked once

01:15:33.280 about this idea of being unconsciously incompetent, consciously incompetent, consciously competent and

01:15:41.280 unconsciously competent. I never got to that fourth stage. So I would vacillate between stage two and

01:15:47.240 three. So I think, you know, I probably just needed the time in the water that said, I would absolutely

01:15:53.720 be feeding a lot different than I fed at the time. I was feeding exclusively on, uh, what the hell was it

01:15:59.660 called? Well, one of the, I used hammer strength, hammer perpetuum. I think it was called not hammer

01:16:03.740 strength. That makes the gym equipment. I think the, I think it's called hammer perpetuum, which was

01:16:08.520 probably the least bad of the high carby fuels. Um, you know, it was multidextrin based. And then I

01:16:15.880 use something that began with a C like cyto mal cyto mix cyto mal is like, it's a thyroid hormone.

01:16:23.740 Didn't use that. Yeah. I think it was called cytomix and I would supplement. I put some stuff

01:16:30.600 in it. I don't remember. Oh, I would put in, no, I would, uh, there was a drink in the UK called

01:16:35.860 maxim. That was a flavorless multidextrin. I would add that to, I would vacillate between the hammer

01:16:42.320 perpetuum and the maxim spiked cytomax. That's what I used to use. And I think what I would do

01:16:50.220 different today is I just wouldn't be a high carb diet. I would be a highly, highly fat adapted,

01:16:55.500 totally different strategy and, you know, rely as little as possible on glycogen for what I was

01:17:02.360 doing. So when I was swimming, my RQ was probably 0.85 to 0.9 most of the time. So meaning I was

01:17:11.740 relying more than half of my energy requirements were coming from, from glycogen or glucose. And by

01:17:18.100 fat adapting, I would, you know, I'd like to, you know, have done those swims at an RQ of 0.75,

01:17:23.760 which would dramatically decrease my requirement. I would probably then instead be using generation

01:17:29.360 UCAN. I'd probably use a bunch of a biosteel as well. I think that was something we weren't paying

01:17:35.000 enough attention at the time to the importance of branch chain amino acids. So that's probably how I

01:17:40.180 would change. Now I'd have to sit down and do the math and experiment at what amounts I would need,

01:17:45.580 but I would probably do. Yeah. I don't know. I could think, I could think of two different ways

01:17:50.380 I'd experiment with it. One would be doing more concentrated, less fluid requiring, especially

01:17:54.580 on the cold water swims where you're not getting as dehydrated and then minimizing the feeding.

01:17:59.200 Cause I used to feed, I think every 20 minutes and I'd do about 250 CC every 20 minutes. And I might,

01:18:05.200 I might change that. I might've gone that. I might've knocked that down to like 250 every 30 minutes

01:18:09.740 at a lower concentration of, you know, alternating UCAN with a biosteel or something.

01:18:14.320 This is a naive question, but how do you refeed and drink while swimming?

01:18:19.460 So it depends on how fast you're trying to go. If you're trying to really go fast,

01:18:23.840 so you're, you have a kayak on the side of you and you're swimming. So if the kayak's on your left,

01:18:29.320 when your right arm is in front, you arch over and you, with your left hand, grab a bottle that's

01:18:36.980 on a carabiner on a rope and you flip on your back, the bottle's already opened. You chug it

01:18:43.160 and drop it and rotate and keep swimming. And it should take about seven seconds to do that.

01:18:50.640 So that's if you're hauling ass, if you are exhausted and you need a break or you need to

01:18:57.200 also pee, you just stop and tread water and grab it and do it. But you can't touch or be touched by

01:19:03.820 the person in the kayak or the boat or anything like that. So that's why the, we would use these,

01:19:10.400 uh, bottles with loops and carabiners and ropes. And we had a big elaborate system and in other

01:19:15.780 swims where I didn't have a kayaker, we built this pole, long ass pole that had a little cup at the

01:19:22.180 end. It's like a fishing pole. Yeah, exactly. And, and, you know, so, and they'd shimmy that thing out

01:19:28.240 from the side of the boat and you'd, for the pole, you couldn't do the rapid feed. It's just too,

01:19:33.560 you know, too many moving pieces, but you could, the rapid feed you'd be taking the kayaker would

01:19:38.180 be standing with their, or would be in the kayak with their arm out to their side perpendicular to

01:19:42.840 create the most distance. So you could come up and grab it. I really loved practicing that. That

01:19:47.060 was like my favorite little ninja move. Interesting. It sounds a lot different than the, uh, at least when

01:19:52.400 I would, I would watch the tour de France. I think they call them the musettes and the slings.

01:19:56.940 The danger there was the people would stand in the middle of the road, the Peloton going by

01:20:01.360 and it was like a magic trick. You would just see it would, it would be gone. And whoever carried the

01:20:06.160 sling would carry the food and carry the food to all the different people. But that's a different

01:20:11.020 ball game. Yeah, that that's real skill. So what do you do for exercise these days? If you're not

01:20:16.760 open water swimming, I still lift weights three days a week. That's kind of like the one staple

01:20:22.680 thing that is non-negotiable in my life. So no matter how busy travel gets or

01:20:26.920 wherever I am, it's, I'm always going to be in the gym sort of Monday, Wednesday, Friday

01:20:31.340 lifting plus or minus some metabolic conditioning thrown in there, depending on, you know, what else

01:20:36.940 is going on these days. I am on the other four days, the Tuesday, Thursday, Saturday, Sunday,

01:20:43.820 I'm riding either the Peloton or the Wahoo kicker, which is like a trainer that you put your bike on

01:20:50.500 and hook it up to something called training. No, I ride trainer road actually as the program that

01:20:55.820 then generates the workout. I have not swum except for a month where I started swimming again in

01:21:03.200 February of this year. I have not really been in the water in a year and a half, which feels really

01:21:08.700 odd given how much swimming was sort of everything in my life for so long. That's probably one thing I'd

01:21:14.760 like to figure out a way to reprioritize is to get back in the water, even twice a week. I miss it

01:21:20.220 so much. And I think there was something, yeah, there's just something in my body misses about

01:21:25.060 that. I also had picked up running again probably three years ago and really started to enjoy it

01:21:33.900 again. It took a year to start enjoying it again. It was that painful for the first year. And then once

01:21:39.020 I started to enjoy it again, I really, I got the itch to, Hey, could I maybe get back to running,

01:21:43.460 you know, a 5k under 18 minutes or something like that. But then, you know, I just got distracted

01:21:49.820 and that's when I kind of got back on the bike. So the bottom line is I don't actually train. I just

01:21:55.000 exercise. So I don't actually do anything that's impressive. I just sort of do my little putz workouts.

01:22:03.120 And I also spend a lot more time on movement prep. So, you know, I take the sort of flexibility

01:22:09.860 movement correction stuff a lot more seriously than I ever did because I've sort of seen the

01:22:15.900 impact of that on injury prevention and the absence of that on injury generation.

01:22:21.920 And you've never done a triathlon. Is that right? So you mentioned, you mentioned run, bike, swim.

01:22:26.520 That's right. I've done all three of those things at one period. I mean, I was a pretty decent runner in

01:22:31.020 high school, a pretty decent cyclist, probably during two periods of my life, at least as a time

01:22:39.520 trialist. And that's basically what a triathlon is and pretty good open water swimmer. So I, yeah,

01:22:46.640 in theory, if you could have taken me from three different chapters of my life, I could have at

01:22:51.880 least done a triathlon. I don't know that I could have ever done it at the level of the guys who are

01:22:56.240 really good. I mean, I have friends who are in the eight to nine hour Ironman category.

01:23:02.060 I don't think that's even theoretically a number I could have hit. I'm not even,

01:23:05.900 I remember one day sitting down and really like going through like what I thought physiologically

01:23:11.140 could be done. I wasn't even sure if I convinced myself I could break 10 hours for an Ironman.

01:23:15.920 And again, I think when you're doing an Ironman, I think for many people, the goal is just to finish

01:23:19.620 the thing, not to break 10 hours. But when I see these guys out there that are breaking nine hours on

01:23:24.080 Ironman, especially people who aren't professional athletes. And, you know, I have friends that are

01:23:28.480 at least two friends who have broken, maybe three friends now that I think about it, who has

01:23:32.120 non-professional athletes have broken nine hours on Ironman. I'm in total awe of that. That, that to

01:23:37.040 me is, that's a remarkable achievement. The distances are you're running a 26.2.

01:23:43.520 Yeah. You're swimming, you're swimming 2.4 miles, which is net. That's a rounding error. You don't even,

01:23:47.680 you can't win the race in the water. You can only lose it. The bike is 112 miles. And then the run is

01:23:53.260 26.2. Looking at exercise in general, a lot of people ask, what's the best exercise for longevity?

01:23:59.840 What is the best exercise to improve muscle mass? And can you expand on lifting weights your entire

01:24:06.660 life as something you should never stop doing? So exercise for longevity, exercise to improve

01:24:12.380 muscle mass and expand on lifting weights. I think the exercise for longevity is a hard question

01:24:19.780 because I don't think we really know the answer. So instead it's probably easier to

01:24:23.500 bifurcate it into two questions, which is exercise to improve lifespan and exercise to improve health

01:24:29.860 span. So how does exercise improve lifespan? Well, it would have to somehow positively contribute to the

01:24:38.360 delay of, or to delaying the onset of atherosclerotic disease, cancer, neurodegenerative disease.

01:24:44.660 I think there's plenty of evidence that suggests that exercise is beneficial in all of those arenas.

01:24:52.680 And then I think the question is through what mechanisms so that you could then go from saying

01:24:58.000 exercise to understanding specifically what it could be. So, you know, cognitively we probably see

01:25:04.420 some benefit from a certain subset of hormones, right? That basically, uh, you know, does BDNF,

01:25:11.380 for example, increase with exercise and what is the impact that that's going to have on brain health

01:25:15.880 on the cardiovascular front and also on the cancer front, my guess, and I think this is true on the

01:25:22.320 dementia front. I think that anything that exercise does that helps you dispose of glucose

01:25:26.800 more efficiently and helps your muscles become better sinks for glucose is probably going to

01:25:32.180 improve things. So I think taking that off the table, cause I think that's sort of the one given

01:25:36.340 the question is, are there benefits on the cardiovascular system specifically from exercise

01:25:41.820 that go beyond that? And I think the answer is probably yes. Like everything, there's a dose.

01:25:47.180 You can also probably exercise too much. And there's probably like all complicated questions. There are

01:25:51.960 people who are more susceptible and less susceptible to the effects of too much exercise. There are people

01:25:56.900 who can get, you know, a certain dose of exercise provides all they need. But that said, I think

01:26:03.500 even more of the benefit of exercise is on health span, meaning enhancing the quality of life and

01:26:11.360 that's cognitive, but also physical. I think too many people confuse health span and lifespan. And you

01:26:17.900 hear too many people say, I don't want to be old because, you know, I don't want to, you know, be

01:26:24.080 decrepit and et cetera, et cetera. But to me, that's sort of like an odd statement to make. It's like,

01:26:29.320 why wouldn't you want to be old and be fit instead? And don't just accept that getting older means,

01:26:35.520 you know, not being able to do things. So, you know, at about the age of 40, it starts to become

01:26:41.560 much harder to maintain muscle mass if you're not deliberately doing something about it. And so that's

01:26:46.080 why I would say lifting weights is probably the single most important thing you can do because I

01:26:50.080 think that muscle mass as you get older becomes an enormous difference between people who are frail

01:26:58.300 and people who are not. And other things matter, of course, certainly bone density and things like

01:27:03.200 that matter. And, you know, getting into how you can optimize those things is beyond the scope of this

01:27:07.820 question. But even within lifting weights, then I would say that, you know, rule number one is don't

01:27:13.900 get hurt. So you see a lot of people, especially younger people doing things that they don't need to be

01:27:19.720 doing. Even I've sort of adjusted what I do relative to what I used to do just based on the

01:27:25.400 trade-off. So I use a hex bar to deadlift instead of a straight bar because frankly, it's a bit easier.

01:27:30.140 You know, it's just, it's easier, it's easier to use my glutes and, you know, I feel like I'm much

01:27:35.560 less likely to hurt my back. Are there benefits of a straight bar over a hex bar? Sure. But the

01:27:41.680 benefits to me aren't worth the risk. When I back squat, pretty rare that I'm going to go over 275,

01:27:47.960 even though as a high schooler, I would put four plates on that bar. But again, I don't power lift.

01:27:55.020 I don't, I'm not competing. Nobody cares how much I lift except me. And I'm not even sure I should care

01:28:02.540 that much. So it's, so I've taken a very different approach. I don't overhead press at all. I only

01:28:09.180 press with dumbbells now, not barbells, even when I'm doing like, you know, any, you know, bench or

01:28:13.800 incline bench or anything like that. So all of my overhead shoulder work is now stability work.

01:28:18.700 Everything that's going to work shoulders below is, is done below the shoulder. And that's had a

01:28:22.780 huge impact on my shoulders. Like they just, and they're totally fine, you know? So you have to

01:28:28.420 learn to make compromises as you, you age, but you shouldn't, at the same time, you shouldn't

01:28:32.940 compromise the, the expectation that you will be strong. You should be able to walk through an

01:28:37.440 airport and carry two 50 pound bags if you need to. Cause if you can do that, if you, if you're

01:28:42.320 already struggling to do that in your forties, you're going to have a really hard time whipping

01:28:46.280 your grandkids around when you're in your seventies. So it's sort of like, how do you

01:28:50.700 minimize how quickly you're going to decline? We went over wearables, but just for the record,

01:28:55.200 what wearables do you use? That's the other question you've mentioned wearing a glucose

01:29:00.080 meter. What devices are out or on the horizon that you'd recommend for more instantaneous feedback

01:29:05.380 than just the scale? I think we got the answer on the CGM and how well does the aura ring

01:29:10.440 hold up doing pull-ups working with barbells, dumbbells, do you use something else for tracking

01:29:16.320 while training? So going back to the CGM thing, there are really are three out there. There's

01:29:20.920 Dexcoms, there's the Libre by Abbott, and then Medtronic has one. I don't think anybody's really

01:29:26.860 using the Medtronic socially. So it's mostly the Dexcom or the Libra. The Libra is cheaper,

01:29:33.080 I believe, and it doesn't require calibration. But other than that, I find it not helpful because

01:29:37.760 as I said, in our hands, both individually and with patients, I think we're seeing accuracies

01:29:43.300 that are plus or minus 20%, which I just think is, that's not good enough. The Dexcom G5 was about

01:29:50.800 plus or minus 7%. The G6, I think is probably plus or minus 3 or 4%. It's so accurate. And of course,

01:29:59.540 the challenge is it'll be a long time, truthfully, before these things are cheap. Because right now,

01:30:05.320 they're not really being targeted towards a consumer market. They're medical devices. And so

01:30:11.780 the economics of these things are very different. They're going through a huge regulatory burden. I

01:30:16.680 mean, the FDA really scrutinizes the way these things work for understandable reason, because if

01:30:21.300 you're going to have a patient dose their insulin based on this thing, it's got to be exceptional.

01:30:26.780 My hope is that in time, as the demand for this in the public increases, there become second tier

01:30:32.600 versions of these things that it's complicated. Because of course, the thing the FDA would always

01:30:37.380 be concerned with is if we allow a less robust version of this to go on the consumer market,

01:30:41.900 will it invariably end up in the hands of people who actually need the more robust version and then

01:30:46.520 make the incorrect diagnostic choice? That's the thing that would keep you up at night if you were

01:30:50.720 doing this. So again, that's just beyond my pay grade to figure out how to solve those problems.

01:30:55.220 But I certainly hope that there's a day, and it's probably four years, five years from now,

01:30:59.680 when the CGMs are really tiny. You've got basically the size of a contact lens. It's a tiny patch. It's a,

01:31:06.520 you know, 400 to 1000 micron needle that you just smack on your belly every day, and you just dispose

01:31:13.200 of it, and away it goes. As far as the Oura Ring, you know, I think I've tried every sort of sleep

01:31:18.640 device out there, and I, you know, I just don't think any of them compare to the Oura Ring in terms

01:31:23.760 of its accuracy. And in part, that's because it's measuring off an arterial waveform, and I think

01:31:29.480 their hardware is better and stuff like that. The only activity I have found that I have to take

01:31:35.320 the ring off for is deadlifts. Because most other things aren't, you're not putting that much weight

01:31:40.780 on it. Like even if your pull-up is only your body weight, even if you're doing a pull-down, like on a

01:31:45.820 machine with more than your body weight, it's not, at least unless you're Bob, that's, it's not that much

01:31:49.560 more than my body weight. Uh, you might not be able to wear one with your pull-ups, uh, or with

01:31:54.580 your pull-downs, but I have, I cracked one doing deadlifts. Uh, so, and I think that's just because

01:32:00.260 it's just sitting right there. But, but most other things, like even with heavy dumbbell presses,

01:32:06.580 it's not really where the weight sits. You know, for me, your finger is actually above the weight and

01:32:11.960 the weight is being rested on your, your palm. So I can't think of another exercise I do. Oh,

01:32:18.760 if I hit the heavy bag, I'll take it off. So I've got another bucket here.

01:32:23.320 I'm going to keep going. Uh, I got a little bit more juice left. All right. Does that mean we're

01:32:27.660 not having fun? I was worried that we would spend way too much time on this and a lot of the stuff

01:32:31.700 here too. We can get into all the, some of the other topics too, that would require another two

01:32:35.880 hours per topic. This one could be one of those, although we might be able to do this thinking about

01:32:42.780 thinking, learning about learning. So there's a few questions here. What is your strategy for

01:32:47.800 learning something deeply? Yeah. This is like a better question for Tim Ferriss.

01:32:52.580 I mean, Tim's codified this stuff. Do you have a particular strategy or how does it go?

01:32:59.560 Is there something you want to know about? I only know one way to really learn things,

01:33:04.200 which is not necessarily efficient, but it's, it's just basically total immersion.

01:33:09.960 It's probably not an accident that when I wanted to learn how to swim,

01:33:13.760 I went to Terry Laughlin and learned to swim via total immersion.

01:33:17.980 So when did you learn how to swim? When was that? Uh, 31, 2004.

01:33:23.160 So when you got into open water swimming, when you realized you wanted to get into open water

01:33:27.740 swimming, you didn't know how to swim. Right. I had to learn how to swim. Okay.

01:33:32.080 It's a necessary condition. So I remember in 2011, when I became maybe 2010, 2011, when I became

01:33:41.600 really interested in lipids, just basically realizing looking at my family history, I'm

01:33:47.420 probably going to die of heart disease. That's sort of how almost every male that I'm related

01:33:53.080 to has died of heart disease. So I knew enough to know one, I probably don't know the answer

01:33:59.460 and two, I should learn about this. And that's when I met Tom Dayspring who became my first teacher

01:34:06.600 on this topic. And since that time remains unquestionably the greatest mentor I've ever

01:34:12.120 had in this space. And I've also got to know guys like Ron Krause and Alan Snyderman and Jamie

01:34:18.120 Underberg. I mean, I could just rattle off the names of all of these guys, Tara Dahl. They've all

01:34:22.420 been incredibly gracious with their insights and their time. But yeah, the approach I took was just

01:34:27.520 like, give it to me all. Don't try to give me the cliff notes. Just I'm going to fricking learn it.

01:34:32.640 At one point I even contemplated going back and doing a fellowship in lipidology. But of course

01:34:38.340 the problem is I couldn't as a surgeon because I had to go back and do internal medicine. I would

01:34:44.060 have to go back and spend two years doing internal medicine. I'd only get one year credit for

01:34:47.580 surgery. So I realized, no, I don't need to become a lipidologist. I can just learn what the

01:34:52.840 lipidologist knows. So it's reading papers, it's watching lectures, but in many ways your learning

01:34:59.040 comes from doing. So I think some of the most interesting things I've learned have been a

01:35:03.820 privilege of just taking care of somebody. So you see a complicated case. Some of my most interesting

01:35:09.960 lessons have been reviewing cases with Tom or Ron or Alan. I went out to visit Tom, I remember once about

01:35:20.060 two years ago for two days, and all we did was review cases for two days. And every time we saw something

01:35:27.840 that was particularly interesting, he would, because he's Tom, just bust open a lecture on

01:35:33.080 that entire topic. And then we'd dig super deep into that stuff. So I think that's just kind of

01:35:38.700 the way I learned. Same sort of approach with trying to learn the hormone systems and learning

01:35:43.940 to drive a car for that matter or whatever it is. It's sort of like you just got to get, at least for

01:35:48.640 me, I don't think I'm a particularly efficient learner. I'm a brute force learner.

01:35:52.400 You revealed something. Tim's probably talked about this, that if you want to expedite your

01:35:57.700 learning, find somebody who's basically already done exactly what you're saying. So what is your

01:36:03.480 strategy for learning something deeply? You basically grab the person who's probably learned

01:36:08.000 this stuff at the deepest level, and you don't let go. You try to extract as much information as

01:36:13.740 possible from that person who's already gone through the process of trying to learn whatever the

01:36:18.400 topic is very deeply. I think that's a... Especially if their way of teaching resonates

01:36:24.780 with you. Math is complicated once you start to get outside of the basics of calculus and algebra.

01:36:31.560 And I just remember there were some professors that they just had a natural way of, at least the way

01:36:37.640 they explained something was the way I was wired to hear it. And then there were others who were

01:36:43.040 brilliant, but I didn't have a goddamn clue what they were talking about. Like I could never really

01:36:47.760 learn from them. So part of it was just knowing how to pick and choose your shots and like who are

01:36:52.980 the people that are going to be, who are going to resonate with you. And it's not necessarily the

01:36:56.100 person who knows it the best. It's a person who can teach it the best, at least during that phase.

01:37:01.540 And then maybe as you get further down, like I don't think anybody could have done for me what Tom did at

01:37:07.660 the outset. Because I just don't think anybody has put that much thought into teaching lipidology

01:37:15.160 in the world. I mean, I really mean that now that I've been at this for quite some time. I don't

01:37:21.060 think anyone on the planet has put more time into teaching and educating and codifying the insights

01:37:28.080 of lipidology and the science of lipoproteins than Tom Tayspring. Now there's, you know, surely

01:37:33.200 somebody out there who knows more than Tom about this stuff, but I can't imagine there's anybody

01:37:37.400 who's thought more about how to teach it. So it was just luck. I mean, you know, I mean, just

01:37:42.180 purely luck that I could fall into, you know, sorts with a guy like Tom and, and, and, and others like

01:37:48.220 that. Well, I think it's could maybe call it the reverse Feynman, but Feynman talks about how to learn

01:37:53.800 something. And it basically comes down to being able to teach it to somebody who doesn't understand it.

01:37:58.940 And you've kind of taken the inverse in some ways too, where you look at teachers and it doesn't

01:38:04.600 necessarily matter what their level of understanding is of that topic. If you're not clicking with that

01:38:09.840 person and it doesn't seem like you're extracting much information, whether you're not a good student

01:38:13.680 or that person's not a good teacher, I think you're relatively quick to say, there's more stuff out

01:38:19.860 there that I could probably latch onto. And I like today with, you know, the internet sound like I'm

01:38:25.740 about a hundred years old, but like with the internet, but you go on YouTube, you can, you

01:38:29.880 can download lectures of all these different people with the Google and the YouTube, with the

01:38:33.380 interwebs, the, the Twitters, with all the GBs and the wifi. The problem is, you know, it's too much

01:38:42.380 information. So part of it is like trying to figure out the person teaching this to me, do they know what

01:38:46.800 they're talking about? Hopefully they do. But then ultimately you have, you have so many different

01:38:51.420 avenues in so many different venues in terms of media. If you, can you listen to it or do you read

01:38:57.240 it or does somebody face to face, does somebody teach it to you? Where I think the answer can be

01:39:02.400 kind of customized to whoever asked that question about your strategy for learning something deeply.

01:39:06.620 I don't think that there's necessarily, well, there's another, there's another thing I've done,

01:39:09.500 which I'd be remiss to not mention is you, you, at some point I've just hired people to help me learn.

01:39:14.840 I mean, that's what you lead is a group of people whose job is to basically help me learn. It's to,

01:39:22.320 it's to basically shortcut the system and cheat by saying, Bob, we have got to know everything about

01:39:29.780 IGF, IGF BP3 and growth hormone. I don't have the time. If I, if I'm going to learn this in detail,

01:39:36.880 it will take three years. If you're going to learn it in detail, it will take three months.

01:39:42.100 I may never actually get to know it as well as you because you will have done all of the heavy

01:39:47.800 lifting and you will have turned tens of thousands of pages into 50 or 100 pages for me. And I know

01:39:57.020 having been the guy that once made those 50 to a hundred page synthesis that the devil was in the

01:40:01.840 details and I had so much nuance around it that I will now give up. But in an effort to, to geometrically

01:40:08.440 increase knowledge, that's probably a price I'm willing to pay. So that's, let me turn the

01:40:12.540 question to you since you have more experience doing this now than me. When Atiyah calls you and

01:40:17.500 he's like, Bob, dude, we've got to know everything about X. What do you do?

01:40:22.620 Some form of total immersion. What I typically try to do, I'm trying to think of some of the stuff,

01:40:27.780 like Tom 40 is a good example.

01:40:29.660 Yeah. So that was about six, a year ago we had to know everything about Tom 40 and its relationship to

01:40:35.220 APOE4. And I knew nothing about it. And I still, there's probably plenty to learn about it. But a

01:40:41.080 lot of times what I'll do is I'll try to find either a paper or a lek, usually a paper because

01:40:46.020 the lectures are actually usually simpler to understand, but something that's kind of complex

01:40:51.360 and I read it and just go, do you specify like a review article that you want to start with? Or do

01:40:57.720 you want to start with primary research? I typically I'll go to a review article that's covered all the

01:41:04.780 stuff that's relatively technical and I'll read it and I won't understand, I don't know, 90% of it

01:41:11.820 or something like that. Uh, but part of it might be just the mindset or the mentality that I think

01:41:16.180 like, wow, this is going to be great when I know all this stuff. And then I try to immerse myself in

01:41:20.600 it. Probably it's like a combination of stuff. YouTube, the lectures, if you can find, this is one

01:41:26.040 of my hacks, I think, although that's kind of a pejorative. I would say that I I've learned that

01:41:30.940 some of the best researchers, when they give talks, they're not necessarily speaking to their

01:41:36.100 colleagues and just geeking out on this stuff. They have to explain it at a lower level. And so

01:41:42.100 I'll watch something, I'll try to watch like the simplest or the easiest stuff, or it's way

01:41:47.500 oversimplified. And I'll watch that lecture and I'll pick something up and it's probably like

01:41:53.040 learning a lot of things, whether it's a sport or an instrument or things like that, that you,

01:41:57.080 maybe it's like a little dopamine hit or something that you pick up something and you feel like you're

01:42:00.560 actually learning something and you, you can now read a sentence in that deep review paper or one

01:42:06.000 of the experiments and you actually understand what it means now at some level. And then I'll try to

01:42:10.880 find a great book on the topic, which for Tom 40, I don't know if there is one. All those of you out

01:42:17.780 there listening, looking for a book to write. It's the Tom 40 story. Yeah. So two Ms. So usually

01:42:25.320 most other topics, you usually be able to find a good book and something that's a, like a

01:42:30.400 relatively fast read. Sometimes you get very lucky and Sid Mukherjee writes the biography of cancer and

01:42:36.700 you want to learn about cancer and you feel like you're reading like a novel, but you're actually

01:42:40.140 learning. You like the best kind of learning is like, you don't even realize that you're learning.

01:42:44.280 It's just like, it seems like it's entertaining. That's probably why sometimes I gravitate to some

01:42:48.220 of the YouTube talks and the people who are good at teaching those things.

01:42:51.400 That's sometimes why when I ask you for a short overview of something, you send me 154 page

01:42:55.880 document on it. Yeah. And it's, and it's probably a sign that I don't understand it all that well.

01:43:00.280 That's the Mark Twain quote that you sometimes talk about. If I had more time, it would be a

01:43:06.000 shorter letter. So to be able to synthesize it and condense it is a challenge. So, so I guess being

01:43:11.420 very specific now that I hear you say that it reminds me of other tricks that I would use.

01:43:15.600 I definitely like to start with the most recent review article on a topic. I never want to start in

01:43:20.280 the primary literature because it doesn't, it's too narrow and I want a larger overview.

01:43:26.620 So for example, like if tomorrow I decided I didn't, if I didn't know anything about LP little

01:43:30.580 a, and I wanted to start from scratch, I would, you know, go into PubMed and search LP little a review.

01:43:36.000 If I was lucky, I'd know who the players in the field were, but generally by looking at the citations,

01:43:41.980 you'd pretty quickly figure out Sam Tamikis is God. And then I would look for the last three review

01:43:48.340 papers Sam Tamikis has written on the topic. I would start by looking at the figures. Once you

01:43:53.180 understand the figures, you actually know what's going on. And then from there I would go. And of

01:43:57.980 course, the other thing I do is I'm just kind of a pushy little prick sometimes. Like I just don't

01:44:03.260 hesitate to reach out to people. You're the same way. Like every week you're emailing the author of

01:44:08.280 some paper. And honestly, I think that they never view it as pushy, even though we feel like, oh,

01:44:12.660 are we being too obnoxious by bugging them? But the reality of it is they love it. This is their

01:44:16.620 life's work. There's like one other geek out there who wants to know everything about their

01:44:20.300 life's work there. Have you, I don't recall you ever getting a response to one of your emails

01:44:24.520 where someone says, piss off. No, I mean, sometimes I may not get a response at all. And I just,

01:44:30.660 I figured some of these people are massively busy, but otherwise they're, it's the opposite,

01:44:35.500 overly helpful. You think, wow. So that's another shortcut, right? It's like, okay,

01:44:40.860 you figured out who the expert is. You've read the review papers. You've, you've got the 80,

01:44:44.460 20 view. Now you look at the experts to help you get the last 20%. Now you want to go 20, 80.

01:44:50.620 Yeah. And for me, it's different than say my wife, who's a journalist. She doesn't mind not

01:44:56.240 knowing a lot about a topic and just finding an expert, grabbing them and asking a lot of

01:45:00.500 questions. I think this is like, it's my ego maybe gets in the way or something like that.

01:45:04.640 I don't want to talk to Sam. I don't know if he's going to say his name, right? Tamikas until

01:45:08.400 I feel like I have a pretty good grasp of what's going on. And this guy's not going to think,

01:45:12.820 what an idiot. But the reality is, he's probably not going to think, wow, what an idiot. He's

01:45:17.280 probably thinking like, this guy's taking an interest in this topic. It's really interesting.

01:45:20.780 But that defense mechanism, I think maybe has helped me in research in some ways where I think

01:45:26.840 I really want to know my stuff before I contact the researchers. But then when you do, they'll usually

01:45:33.160 give you more insight, better insight, and a different way of looking at things. And even with the papers

01:45:40.020 themselves, oftentimes, when you talk to the author, you get a different perspective, even

01:45:45.020 from you read, word for word, you read the paper, but they tell you about all the sort of like how

01:45:50.620 the sausage is made. And the things that they had to take out of the paper, because maybe they didn't

01:45:55.160 have enough evidence to support it. Or the editors were like, the paper's too long. You got to take

01:46:00.020 this out. Yeah, you're going to get a much more interesting story.

01:46:03.020 Yeah, I don't know if that was helpful. But I think part of it is you really, whatever it is,

01:46:06.060 you really want to have to, you have to buy in, I think, as well. Because I think a lot of people

01:46:10.540 are looking for a shortcut, maybe. But a lot of what you're talking about, too, with exercise and

01:46:15.260 research and things like that, where you get immersed in stuff, it's sort of carry water,

01:46:20.180 chop wood, and don't stop. Just do it relentlessly. I mean, it doesn't have to be burning the candle at

01:46:26.900 both ends, necessarily. But it just has to be continuous and relentless. And you have to keep moving in one

01:46:31.840 direction, I think. And you can take a bunch of different approaches. But you really have to want

01:46:36.260 to learn the stuff. There's just so much information about virtually everything that you would want to

01:46:41.000 know. You can get like a free education that's probably better than any education that was out

01:46:46.060 there, other than the people that you can meet and talk to. And I think that that's huge. So this is

01:46:51.840 sort of the flip side. In your life to date, what did you waste the most time doing? And what do you

01:46:56.880 wish you'd done with that time instead? This is going to sound like a shitty answer and a cop-out,

01:47:02.320 but I really mean it. It's not any activity or thing that I've done. I don't regret all the time

01:47:10.180 I spent boxing and doing martial arts, even though you could argue that I'm worse off for the

01:47:15.800 concussions. I mean, I had some bad ones. I had one really bad one where I was hospitalized, and

01:47:20.740 I'm convinced I'm 20 IQ points lighter than I should have been as a result of that. And so it'd be

01:47:26.520 easy to say, well, I, and I, and I have at times thought, oh God, I wish I, why didn't I just play

01:47:31.200 basketball instead or something where I didn't like get brain damage. But I don't because I know that

01:47:37.080 boxing without boxing, I could have never done what I did after. You know, I could have never gone to

01:47:41.500 college without it. And in terms of the discipline it taught me, what I really regret is the time I've

01:47:47.660 wasted thinking about things I couldn't change. It's the amount of time and energy I have wasted on

01:47:55.240 things that don't matter. And I don't mean that in activity. I mean that in dysfunctional emotion,

01:48:03.280 you know, it's the amount of time I thought about that ex-girlfriend and, you know, for a year

01:48:09.400 pined over her and wondered, you know, why she dumped me or something like that instead of just

01:48:14.340 moving on, you know, or the amount of time that I spent pissed off at that person who did something

01:48:22.220 bad to me. I actually think that that's the shit we have to be guarded against. Did I watch too much

01:48:29.360 TV as a kid? I don't know, probably not by today's standards, but yes, I've thought many times, oh, I

01:48:35.860 wish my parents forced me to learn six languages when I was a kid instead of letting me do any dumb

01:48:41.520 shit like playing with firecrackers and running around the neighborhood or whatever. But you got to

01:48:46.000 be careful with those things. You know, maybe I'd be a different person today if I'd been, you know,

01:48:49.960 raised in an environment where my parents were constantly forcing me to be hyper efficient or

01:48:54.520 whatever. So yeah, look, I wish there were many things I had spent time learning that I didn't

01:48:59.620 learn, but at the same time, I'm not sure I'm willing to give up the six hours a day, six days

01:49:03.680 a week I put into training when I was growing up. But I think I've wasted way too much time worrying

01:49:10.120 about things that don't matter, worrying about things I can't change and not spending enough time

01:49:15.160 in the present with the people who are sitting right in front of me who matter. So that's,

01:49:19.660 that's probably my biggest regret on that front. What impact did your upbringing have on your insane

01:49:25.120 career path slash constant drive? Oh, this is a tough one. I don't know if I can talk about this

01:49:31.260 shit publicly. I think, uh, I would just say this. I think I am fortunate that I found largely

01:49:40.600 productive outlets for my obsessions and my numbing of pain, which I think everybody has.

01:49:49.940 And so all of these, all of the things that have impacted us in those way are largely

01:49:54.800 two-edged swords. You know, I think things happen to kids that make them want to be special,

01:50:04.600 make them want to be better. And sometimes that gets channeled into doing things that are ostensibly

01:50:10.540 bad, quote unquote, or ostensibly good, quote unquote. I don't want to discount the positive

01:50:16.540 effect my parents have had on my life because I think it has been positive. But unfortunately,

01:50:22.060 I'm also aware that much of my drive is probably unhealthy and probably stems from unhealthy

01:50:28.040 events that, uh, yeah, I don't, I don't really want to talk about.

01:50:33.560 Yeah. So this one's related to thinking, I'd like to know what your process is for forming

01:50:39.980 your beliefs. There seem to be a lot of narratives slash absolutes that people get stuck on in the

01:50:47.040 nutrition world and really miss the quote, it depends, end quote, part that you seem to have.

01:50:54.440 I don't know if I can attribute this to Feynman, but certainly someone I admire has made the point

01:51:00.600 that most facts have a half-life. So I think that's kind of the first thing you have to wed yourself

01:51:06.080 to is there's a chance that what I think I know today won't be true tomorrow. And you just have

01:51:13.380 to keep that softly in your mind. You don't have to like wake up and berate yourself with that fact

01:51:18.380 every day, but you just got to softly remind yourself that, look, I think this is true. I may have

01:51:25.060 mentioned this on a podcast once before, but you know, in mathematics, there were proofs,

01:51:29.580 but in biology, there are no proofs. You don't prove anything. An experiment proves nothing. And

01:51:36.560 this something Feynman has stated very eloquently, actually tweeted it, I don't know, a couple of

01:51:40.540 months ago, something to the effect of like, all we do in science is basically increase the

01:51:45.740 probability that we believe something is actually true, but there's no, there's no definitive

01:51:49.720 proof of anything. I mean, even frankly, you know, Newtonian physics, which seemed all but said and

01:51:57.360 proved until relativity came along. I mean, it's all probabilistic. So I think if you, if you just show

01:52:04.980 up with the mindset that says, look, we're looking to increase our knowledge by gaining confidence in

01:52:11.960 the probability that certain things are true or not true, you just get a little bit of the humility

01:52:17.740 that says, yeah, I got to be ready for this to not be true one day. And look, there are things I

01:52:23.180 believed five, six, seven years ago that I still believe are true. And there are things that I

01:52:29.100 believe then that I don't think are true. In all cases, I think I've just appreciated more nuance,

01:52:34.420 more exceptions to the rules. And I, and I think the other thing is, this is something I think we have

01:52:41.500 the luxury of doing by the nature of the way the practice is set up is it's primarily like a

01:52:47.260 knowledge acquisition grab. So we're kind of not wetting ourselves to the notion that we are, we

01:52:55.720 have to be right. We're wetting ourselves to, we want to know the most. And I talked about this, I think

01:53:01.020 on the podcast with Patrick, um, a Shaughnessy once, but if you think more about how can I know the most

01:53:09.060 rather than how can I be right the most? I think that also takes a little bit of the edge off.

01:53:14.460 My brother actually has a, you know, it's a relatively recent movie, but remember Charlie

01:53:19.140 Wilson's war, there's a scene near the very end when, you know, the Americans are kind of,

01:53:25.000 you know, happy and obviously the Russians have retreated. And, and, uh, now the question is like,

01:53:31.200 what should the U S be doing to support Afghanistan? And Gus is making this point and I'm going to

01:53:37.120 bastardize this. Hopefully we can find the clip and link to it. Do you know what I'm talking about?

01:53:40.540 Where he's telling the story about the, you know, the boy gets a horse and everyone says,

01:53:45.860 oh, so good for the boy. And Gus goes, eh, it depends. And then the boy's on the horse and he

01:53:51.040 falls off the horse and he breaks his leg. And everyone's like, oh my God, it's so sad. He's

01:53:54.900 like, eh, we'll see. Right. And then there's a war that comes in. All the boys have to go off to war,

01:54:00.660 except the boy who broke his leg and all the boys that go off to war died. Everyone's like,

01:54:04.740 oh, it's so great. We'll see. And you can, the story keeps going. I don't want to say anymore

01:54:09.380 because I've already probably screwed it up 10 ways to Sunday, but I just love the approach of

01:54:14.140 like, eh, we'll see. I mean, we don't really know shit and we certainly don't have a crystal ball.

01:54:19.820 I mean, which is not to say I don't have conviction about certain things. I have conviction about a lot

01:54:23.700 of things. And the challenge of medicine is you do have to make decisions. So you don't always have

01:54:28.840 the luxury of saying, we'll see, we're going to do nothing because there's a risk of doing nothing.

01:54:32.560 And so when I have patients that say, Peter, I don't want to do this because you can't give me

01:54:37.500 a 100% chance that it's the right decision. I say, that's fine. But I have a much higher belief that

01:54:43.560 if we do nothing, the outcome is this. And that's worse on a risk adjusted basis than the outcome

01:54:48.960 of doing something, even though I can't guarantee you it's a perfect outcome. And that's maybe a bit

01:54:53.540 cumbersome in concept, but I think that's an important thing to keep in mind as the other end of

01:54:57.860 this is you don't want to be paralyzed in your inability to make a decision because of uncertainty.

01:55:03.880 If you need absolute certainty to do everything, you have to play checkers or chess for that matter.

01:55:10.260 As important as a game as chess is, in the end, it doesn't mirror life because you have complete

01:55:15.960 knowledge at all the time. At every point in the game, you have, both players have complete knowledge.

01:55:20.860 In many ways, poker is a better example of life because you never have complete knowledge.

01:55:26.080 Yes, the probabilities can help you. And there is difference between good players and bad players.

01:55:31.680 Those who understand the probabilities, those who don't, those who, but more importantly,

01:55:34.940 it's like, what can people read and not read? And I think the analog in life is not about

01:55:39.440 necessarily reading people, but it's about being able to think about data when there's an incomplete

01:55:43.800 set. I think a couple of Feynman quotes, first principle, so you must not fool yourself and you're

01:55:50.420 the easiest person to fool. And then he once said that his definition of science is the belief and

01:55:58.000 the ignorance of experts. And I think sometimes people use that as like a tool to wield against,

01:56:03.120 you know, any, any Sam Tamikis out there who knows everything about, you know, doesn't know

01:56:08.100 everything, but knows a lot. And you can just be like, oh, well, you know, Feynman says you're

01:56:12.280 ignorant. I always turn that one on myself and think like, I'm trying to learn about this stuff,

01:56:16.560 but like, never forget that you're ignorant. There's a lot that you don't know. And one of

01:56:20.740 the things that is apparent to me, at least when you think about it, is that as you get older and

01:56:26.340 if you've been in a game where you're trying to learn a lot or you're trying to grow or better

01:56:30.940 yourself, think back to five years ago on some topic that you've learned a lot about. So I imagine

01:56:36.240 if you think about lipidology and you think back to five years ago and think, I knew nothing about

01:56:43.660 that subject or something like that. But a part of you five years ago thought, oh, I know way more

01:56:48.400 about, you know, if your ego gets in the way, you think like, I know way more about this stuff that

01:56:52.420 I'm going to start saying things with, you know, platitudes or certitudes about my confidence in

01:56:57.460 what I know. But I do think like nutrition just lends itself to, you can be so sure of something

01:57:04.500 because it's, you can never really be proven right or wrong. If you're going to be using,

01:57:08.600 I don't know, epidemiology, it's sort of like you're kind of right, you're kind of wrong, but you can

01:57:14.300 never really be proven wrong necessarily. So it's, it's, it's pretty easy, I think, to, to go out on a

01:57:19.860 limb, so to speak, and say something's really good or really bad. And you can gather all the information,

01:57:25.640 you can collect all the confirmation bias you want, and it's going to be really hard to disprove,

01:57:31.720 you know, your theory, you know, if it disagrees with experiment, it's wrong. You know,

01:57:36.500 Feynman says, it's like, we don't do experiments. Yeah. And you'd need to, we'll probably link,

01:57:41.940 I mean, to Feynman and his New York, Brooklyn accent is unparalleled. We've got a couple of

01:57:48.000 questions about your diet. Why did you decide to discontinue your ketogenic diet? What differences

01:57:55.280 in your health and performance have you noticed since? And what does your diet look like these days?

01:58:02.280 Well, I, um, I discontinued a ketogenic diet after three years. In the moment when I discontinued it,

01:58:08.980 it was basically like, I was just missing my all singing, all dancing, famous curry stir fry,

01:58:15.120 which was like probably my staple meal in college and med school. And, you know, throughout most of

01:58:21.020 life, that was like probably my favorite meal. And, um, so on a bed of rice, I would put this huge

01:58:27.620 curry stir fry that had like all of these awesome vegetables and very spicy and blah, blah, blah,

01:58:33.980 blah. But, you know, you couldn't eat that in ketosis, even without the rice, because just that

01:58:38.380 volume of vegetables would usually boot you out. And certainly with the rice, you were going to be

01:58:43.000 gone. And I was just kind of like, you know, I just miss this. I just need to start eating this again.

01:58:48.560 Also, I was kind of missing certain fruits. I felt like I was just like, not, again, I didn't feel like

01:58:54.820 I needed them from a health wise perspective. I just felt like I just miss them. I enjoy eating

01:58:58.800 these things. I haven't had a banana in three fricking years, except for the hot one, you know,

01:59:02.780 or something like that. So it just, for me, it was just that, that was what it really came down to.

01:59:06.940 And, you know, I think the impact of leave, you know, different people have different responses to

01:59:11.260 a ketogenic diet. I think some people at my end of the spectrum respond as well as anyone can respond.

01:59:16.900 I mean, for me, it was, I mean, it's hard to articulate, right? I mean, every, on every dimension,

01:59:22.720 things just got better. I mean, my mental clarity, my resilience, my biomarkers, my performance.

01:59:30.580 Eventually it did take a while. I certainly took a step backwards for the first three months,

01:59:36.200 then regained mostly aerobic function. It was probably 18 months before I surpassed anaerobic

01:59:41.800 function. And I was actually with Steve Finney last week, and we were talking about this, that I really

01:59:47.220 regret not taking muscle biopsies throughout that three-year journey. I think that could have been

01:59:51.100 quite insightful. But I also know, having now put people on ketogenic diets and been around a lot

01:59:58.160 of, you know, people on ketogenic diets, that I was about as good a responder as you're going to see.

02:00:02.700 And there are others that have responded as well as me, but there are lots of people who don't

02:00:06.700 respond this well. And so, you know, going back to the previous question, I think that's where you

02:00:10.200 have to have a little bit of humility, which is like, you know, no offense to the keto community

02:00:14.420 out there who I'm probably pissing off at the moment, but I'm highly put off by the,

02:00:18.780 this view that like ketosis is for everybody. And if, you know, if you try a ketogenic diet and it

02:00:23.760 doesn't work for you, well, you screwed it up or something. And it's just like,

02:00:27.280 that just strikes me as patently false. So anyway, that's, I don't know if I answered the

02:00:31.880 question. Was the question, what, okay. Oh, then the other question is, what do I do now?

02:00:34.980 Now I mostly vacillate between time-restricted feeding and non-time-restricted feeding with a

02:00:41.660 much simpler set of principles on how I eat, which is just try not to eat junk.

02:00:45.580 So I don't really restrict my carbohydrates deliberately at all anymore, which I know is

02:00:52.020 going to sound crazy to people listening to this, but I just restrict bad carbohydrates.

02:00:57.460 And as a general rule, if it comes in a package, it shouldn't be eaten. So like the Weethans,

02:01:02.060 like there's, there's no rule for Weethans in the diet, right?

02:01:05.880 I'm sure there's a Weethans tree somewhere.

02:01:08.320 Those are our paleo ancestors. Were you there? Were you there? Are you sure there wasn't a tree?

02:01:14.300 You know, it's a very good point. I wasn't there. It's quite possible that Weethans grew on trees

02:01:19.500 with, with graham crackers. My favorite, my go-to starches, you know, I definitely like potatoes and

02:01:24.620 I definitely like rice and I probably will, you know, if there's seven days in a week, uh, four of

02:01:30.200 them, I'll be eating those with at least one of my meals. So yesterday I usually, I'm not eating

02:01:36.200 breakfast still. So yesterday when I woke up, you know, did my morning routine, rode the Peloton for

02:01:42.240 45 minutes, had, you know, made a, my coffee, my special fancy coffee after that and putzed around

02:01:49.260 and like worked and, you know, whatever did all my, you know, saw patients did this, that, and the

02:01:52.800 other thing came back to my apartment at two, still hadn't eaten and then made a shake. So I make this

02:02:01.260 shake called, I call the Peter Kaufman, which I wrote about on the blog like six years ago, which

02:02:05.720 is a little bit of heavy cream, almond milk, frozen strawberries, spoon of almond butter, and then a

02:02:11.860 you can protein, chocolate protein, uh, with a ton of ice. So it makes, we're going to have one right

02:02:16.800 after this, by the way, in about five minutes. So salivating for the Peter Kaufman. And so that's a

02:02:22.200 pretty high fat shake where the only carb you're getting is the super starch, which basically doesn't

02:02:27.520 act like a carb. You obviously get some in the almond butter and there's virtually none in the

02:02:31.500 frozen strawberries. And then that evening, yesterday evening, so I didn't eat anything

02:02:36.400 else the rest of the day, obviously just, you know, I had like water or something like that.

02:02:39.980 And then in the evening I went out for dinner with a friend and we went to a Greek place and,

02:02:45.260 you know, I had a smoked salmon appetizer. It did come with like little pita chip breads,

02:02:50.060 which I didn't eat. Although in truth, I will often eat those because I freaking love them. But just

02:02:54.060 yesterday, I didn't feel like eating them. And then I got a lamb entree that came with some

02:02:59.320 potatoes, these lemon potatoes that these guys make that are ridiculous. You know, no dessert came

02:03:06.920 home, had some tea. That was it. So when I look at my CGM from yesterday, my highest glucose was about

02:03:16.160 two hours after dinner, maybe an hour after dinner, but it was about 117 milligrams per deciliter.

02:03:24.060 It was my peak glucose yesterday. And the other thing I really pay close attention to is what was

02:03:28.720 my peak nighttime glucose. So by the time I went to bed, it was down to 90. And, you know, I think my

02:03:34.800 peak nighttime yesterday was 95, which makes me really happy because I almost always see my highest

02:03:40.520 glucoses at night. They're almost always, I think, in response to cortisol. So today we'll have one of

02:03:47.200 those shakes for lunch. Maybe we'll go work out, then we'll shake. And then for dinner, I don't know what

02:03:52.900 we'll do, but it'll be basically the same sort of thing. It'll probably be, oh, I also had a big

02:03:56.740 salad yesterday. I forgot to mention that the smoked salmon, the big ass Greek salad in a bowl,

02:04:01.600 the size of my head. And then the, uh, the lamb with the potatoes. So I'm kind of a boring eater

02:04:08.980 actually, which is, I like to have lots of vegetables, including salad. I usually rotate,

02:04:14.800 you know, lamb, beef, fish, and then at least half the time, if not more, maybe a bit of potato or

02:04:21.500 rice. I think you might've tipped your hand when you, you did a regimented three year, pretty much

02:04:27.620 all on ketogenic diet. And what kicked you out of a ketogenic diet was your longing for vegetables and

02:04:35.980 fruit more or less. And then on the exercise side, not doing the muscle biopsies or something like

02:04:41.760 that. So I think most people might be going for the chocolate cake. Although you did, you did have

02:04:47.940 one. I had that one day. Yeah. Or I had six desserts in one sitting, you know, I I'm sure I'll go

02:04:54.820 anytime I'm with my like keto friends, like last week when I was up with Steve Finney and a whole

02:05:01.220 bunch of the people from Virta health, I swear, I was like, that's it, man. I'm going back on a

02:05:05.420 keto, you know, I'm going to go back on a ketogenic diet. And then I got home and I was like,

02:05:09.740 nah, I don't feel like it. That's just, and honestly, part of it, this is a total cop out,

02:05:15.940 but part of it is just like, it's a pain in the ass with kids. I don't want to get into weird stuff

02:05:20.680 with my kids again. Cause I remember when I was on ketogenic, my daughter was always asking me why I

02:05:24.100 didn't eat this, why I didn't eat that. And I feel like, and again, I'm not knocking a ketogenic diet

02:05:29.000 and I think I could, I could do it and do it in a responsible, sustainable way as far as my kids.

02:05:33.920 But I like now talking to my, only my daughter, my sons, obviously we don't talk about this stuff

02:05:41.460 yet. They're not old enough, but, but with Olivia, there's definitely a lot of talk of like the other

02:05:46.360 day, like, you know, it was her birthday and, and so there was a ton of ice cream left in the fridge

02:05:50.160 and she came home from school and she's like, daddy, can I have a bowl of ice cream? And I was

02:05:53.180 like, hell no, you can't have a bowl of ice cream. What the hell are you talking about? She's like,

02:05:57.240 well, mommy lets me. And I was like, I'm pretty sure mommy doesn't let you have ice cream before

02:06:00.860 dinner. And don't you get how bad that stuff is? Like you get to have that once in a while as a

02:06:06.040 treat, but like that didn't grow on a tree that didn't, you know, come out of, you know, like

02:06:11.300 that's fake food. Right. And, and so it's, there's still the opportunity to talk about that. And, and,

02:06:17.240 you know, I like that they're seeing me eat a broader array of food now than I would be if I

02:06:23.500 were on a ketogenic diet. Cause when I was on a ketogenic diet, the other thing is I was on such a

02:06:27.620 high calorie ketogenic diet that I had to eat so much weird stuff. Like I had to basically eat a

02:06:32.980 tub of sour cream every day just to get my 4,500 calories that I needed. What was your ratio of

02:06:40.860 a ketogenic diet for epileptic? Yeah, I was, um, they talk about carbs to protein. Yeah. So I did

02:06:48.220 it in total percent. I did it as a percent of total calories and I was fat to protein and carbs. Yeah.

02:06:52.200 I was about 90% fat, about 7% protein, 3% carbohydrate. And the reason that my percents

02:07:00.020 were so high in fat is that my total caloric intake was probably 44 to 4,500 calories a day.

02:07:06.400 But I was exercising like crazy. Yeah. I always, I marvel at what a ketogenic diet

02:07:10.760 sort of technically is. I mean, if you're looking at like the Hopkins ketogenic diet where it's,

02:07:15.520 it's four to one fat to protein and carbs in terms of, I think by weight. So if you're,

02:07:21.340 if you're eating a hundred grams of protein and carbs, you're eating 400 grams of fat,

02:07:26.160 which is 3,600 calories. So you're looking at a 4,000 calorie diet, probably close to what you,

02:07:30.120 maybe what you're doing, right? 75 grams of protein, maybe 25 carbs, maybe lower.

02:07:34.920 And you're doing that. And you don't realize like that does take effort. It's not just like,

02:07:39.880 I'm just going to eat some meat and I'm gonna eat some vegetables and some nuts and seeds.

02:07:43.200 It's huge effort unless you have the luxury of, you know, a chef or prepared meals. Like I don't

02:07:49.320 know if quest is doing it anymore, but they were at one point doing like pre-made two to one,

02:07:54.140 three to one, four to one keto meals. And I think they were doing it with the Charlie foundation

02:07:58.720 actually for the kids with epilepsy. And I ate a bunch of those like just as trying them out. And

02:08:03.640 I mean, they were great. I could mainline those things. If someone were like feeding me those all

02:08:08.600 day. Yeah. I could go back on ketosis with, but maybe I'm just too lazy. I don't know.

02:08:14.820 So I know you said that there were questions on stuff that we've already either done a podcast

02:08:19.920 on or we'll be doing a podcast on. So we'll punt on those. Do you want to, what, what are those

02:08:24.600 topics? So we have a lot of topics around statins. What are those? So when would you use them?

02:08:33.460 Why do you never heard of them? Never heard of them. You were talking about Tylenol before I was

02:08:40.860 drawing a blank too. Uh, smart drugs and supplements. So drugs and supplements for

02:08:46.600 cognition, also smart drugs, drugs for also drugs and supplements for performance,

02:08:50.960 heat and cold therapy. It's a really interesting topic. I'm sure we'll dig into that too. Uh, HRT,

02:08:56.700 I believe HRT, at least a estrogen and hormone replacement therapy and women

02:09:00.460 was on your poll. It was either HRT or LP little a for the first topic. So I'm sure that might get

02:09:06.060 thrown back into the mix. That's right. Yeah. And I think LP little a one hands down like 80 20,

02:09:10.260 but we'll definitely be taught. We'll definitely do a dedicated thing on estrogen and HRT.

02:09:16.140 Okay. Autophagy, uh, ApoE, which we got into a little bit and depression,

02:09:22.300 sort of what genetic effects, environmental effects, and how do you handle it?

02:09:26.340 So I'm going to be, I reached out to one of my best friends who's a brilliant psychiatrist,

02:09:31.100 Paul Conti, and actually, uh, just a couple of days ago and said, Hey, let's do a podcast.

02:09:36.060 And I want to talk all about depression, everything about it, environmental triggers,

02:09:40.420 the genetics of it, treatment strategies, all that stuff. So Paul is totally game to do that.

02:09:45.920 So we're, we're going to do that podcast this summer. Uh, we're going to be talking to Rhonda

02:09:49.700 Patrick soon. We're going to get, I'm sure Rhonda is just, we're going to have so many great things

02:09:53.460 to talk about. So I'm sure a lot of the heat and cold smart drug stuff will probably come up there.

02:09:57.180 We're going to do one with Dom D'Agostino soon, and that's going to get into a lot of ketosis

02:10:02.280 stuff. We've already done a great one with Ron Krauss, and that's going to touch on all of the

02:10:07.100 statin stuff. Autophagy. Yeah, we'll probably have to, well, we actually, did we, uh, does the

02:10:12.800 Sabatini one? No, but we've got the other MIT ones that get into autophagy. Oh yeah, Greg and Monther

02:10:17.020 at MIT. So I think we've got some, yeah, so we've got some great stuff there. We do need to probably

02:10:22.360 do a dedicated APOE one. And I think we'll definitely get into exercise. In fact, I'm

02:10:28.320 going to be speaking with Mark and Chris Bell this summer. It's odd because we don't know when this

02:10:33.940 is actually going to be released. So I guess we're going to release this one early so that what I'm

02:10:38.680 saying makes sense. But, uh, so with Mark and Chris Bell, I'm sure we'll have plenty of chance to talk

02:10:42.840 about exercise, especially around strength training, hypertrophy and things like that. So I think we got it.

02:10:47.640 Is there any other question that we need to get at before we either go make a shake or go?

02:10:54.360 No, I think that's good. I think hopefully we'll do more of these so we can reload and do some more.

02:10:59.660 All right, man. Well, thank you for compiling all of these. My pleasure. I loved being able to not

02:11:04.880 have to pay attention to any of those questions on Twitter and knowing that you were, you were,

02:11:08.780 you were caught. Oh, oh, that's the, so one, one quick thing with, with, it's funny because I think

02:11:14.380 everybody goes through this where they think, um, you know, I'm getting off of social media.

02:11:17.840 I'm getting off of Twitter. I'm getting off of Facebook. It's just, it's doing me no good.

02:11:21.600 I need to just, you know, like the first question I need to get back out into nature. I think this

02:11:25.760 is doing more harm than good and distraction. And then Peter says, you're going to need to get on

02:11:30.860 this Twitter and, uh, start handling these questions and, you know, these, the Twitter wars and

02:11:35.600 things like that. But it really was a pleasure. I was like all the questions that you got were,

02:11:39.700 I don't want to say all of them, but most of them at least were excellent. And I, I'm just,

02:11:43.880 I'm looking at the master list and there is stuff. There's NAD and nicotinamide, riboside and, uh,

02:11:50.400 terastilbene. Oh God, we've got all that stuff. So NAD, NAD plus.

02:11:55.720 So you've shielded me for most of these questions.

02:11:59.240 Mostly. Yes. Okay. All right. Well maybe we'll figure out,

02:12:02.480 take a look at what you've got here versus there. And we can decide if this is something

02:12:05.200 we should be doing quarterly or what's the frequency with which we could do AMAs. I mean,

02:12:08.920 I think we got a lot of sort of nothing burger questions out of the way that probably don't come up

02:12:13.180 again, like race car driving questions and childhood questions, but you know, we'll go from

02:12:17.920 there. All right, man. Well, listen, thank you very much. And thank you everybody for submitting

02:12:22.880 your questions. Uh, I hope that this format made sense and wasn't a complete waste of time.

02:12:28.440 You can find all of this information and more at peteratiamd.com forward slash podcast.

02:12:35.860 There you'll find the show notes, readings, and links related to this episode. You can also find

02:12:40.940 my blog and the nerd safari at peteratiamd.com. What's a nerd safari you ask? Just click on the

02:12:46.960 link at the top of the site to learn more. Maybe the simplest thing to do is to sign up for my

02:12:50.960 subjectively non lame once a week email, where I'll update you on what I've been up to,

02:12:55.140 the most interesting papers I've read and all things related to longevity, science, performance,

02:13:00.300 sleep, et cetera. On social, you can find me on Twitter, Instagram, and Facebook all with the ID

02:13:05.640 peteratiamd, but usually Twitter is the best way to reach me to share your questions and comments.

02:13:10.820 Now for the obligatory disclaimer, this podcast is for general informational purposes only and does

02:13:15.400 not constitute the practice of medicine, nursing, or other professional healthcare services,

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02:13:25.140 The use of this information and the materials linked to the podcast is at the user's own risk.

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02:13:40.680 condition they have and should seek the assistance of their healthcare professionals for any such

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The Peter Attia Drive - July 09, 2018

#04 - AMA #1： alcohol, best lab tests, wearables, finding the right doc, racing, and more

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