The Peter Attia Drive - #145 - AMA #19： Deep dive on Zone 2 training, magnesium supplementation, and how to engage with your doctor

00:00:00.000 Hey everyone, welcome to a sneak peek, ask me anything or AMA episode of the drive podcast.

00:00:16.500 I'm your host, Peter Atiyah. At the end of this short episode, I'll explain how you can

00:00:20.460 access the AMA episodes in full, along with a ton of other membership benefits we've created,

00:00:25.440 or you can learn more now by going to peteratiyahmd.com forward slash subscribe.

00:00:31.120 So without further delay, here's today's sneak peek of the ask me anything episode.

00:00:39.200 Welcome to ask me anything. I'm once again joined by my head of research, Bob Kaplan in this episode,

00:00:46.920 AKA Ron Tugnut. In today's episode, we go really deep on zone two. We touch on exercise a little

00:00:56.460 bit more broadly than that. And we get into a few other tangents outside of zone two, like what is

00:01:00.960 FTP zone five, you know, some of the anaerobic stuff, but mostly this is a super deep dive into

00:01:07.880 zone two from a practical level. So if you heard the Inigo San Milan podcast, you'll have obviously

00:01:15.240 an understanding of what that is. If not, don't worry because we revisit it. But more importantly,

00:01:19.440 I think we kind of get into the how to do it. What's the dose, what type of exercise, what type

00:01:24.900 of machines, the frequency, what if your numbers look like this, you know, all of that kind of stuff.

00:01:29.760 So I hope by the end of this episode, you'll really understand how to bring zone two in as one of the

00:01:35.540 four pillars to your exercise program. The other two things we get into in this episode are a kind

00:01:41.760 of lowdown on magnesium. So we had a great question about, Hey, Peter keeps talking about

00:01:46.840 this type of magnesium, that type of magnesium, this type of magnesium. Can you give us the skinny

00:01:50.720 on that? And so we get into that and then we close it out with a short discussion on the,

00:01:58.600 how do you actually talk to your doctor about some of the stuff that we're getting into here?

00:02:03.060 A couple of weeks ago, actually a couple of months ago now, we had a newsletter that talked about

00:02:08.060 early screening or more aggressive screening on colonoscopy, which is a sort of point of view

00:02:12.300 that I have. And there were many questions from listeners saying, Hey, look, sure. That'd be one

00:02:16.840 thing. If you were my doctor, we could have this discussion, but having this discussion with my

00:02:20.140 doctor was actually much more difficult. And so I try to offer as many insights as I can into how

00:02:25.060 one would go about doing that without being off putting and obviously trying to get the best care

00:02:29.760 you can. So without further delay, I hope you will enjoy. Hey, Peter, how are you doing? Ron

00:02:42.460 Tugnut. How are you? The one and only I'm doing pretty well. I feel like our AMAs have turned into

00:02:50.080 basically a game of hockey obscurity, where every time we meet on video, you've got a different 1980s

00:02:58.180 slash 90s goalie as your ID. That's right. Growing up, just loved the Bruins and hated every other

00:03:05.220 team, but I had a lot of respect for Ron Tugnut. Boston Bruins saved 70 shots in a 3-3 tie. It's

00:03:13.420 just absolutely unbelievable. It's on YouTube. Check it out. Just some of the saves that he was

00:03:17.660 making was just unreal. It's a great game. Yeah. Mr. Tugnut actually is from my home borough of

00:03:24.920 Scarborough, Ontario, the little crappy outpost of Toronto. I remember that. We've got a nice Easter

00:03:31.200 egg if anybody cares to look in the Studying Studies series. If you go to, I think it's Studying

00:03:36.900 Studies part two, and I think it's figure two. It's about chimney sweeps. Check out that figure

00:03:43.900 caption. It's pretty impressive. I forgot about that. Thanks for reminding me. Yeah, you approved it.

00:03:51.440 So, it's there. What do we have on my docket today for Ask Me Anything?

00:03:57.720 We have a lot of questions related to exercise and zone two. We also have a few questions around

00:04:06.180 magnesium, and then we got a lot of follow-up questions on a couple of weekly emails, which

00:04:11.800 were, I think the earlier one was how to find a good doctor and the questions that you should ask of a

00:04:16.700 doctor. And then we also had a weekly email on colorectal cancer and colonoscopy and a lot of

00:04:23.040 questions that you should ask your GI doc before getting a colonoscopy. And we had a lot of questions

00:04:27.060 around how should I approach my doctor with these questions? Is there a way to do that that's most

00:04:32.000 effective? If we can get through all of that in one episode, I'll be delighted, but let's see how far

00:04:37.520 we can. Absolutely. Okay. Zone two in exercise questions. First, type of exercise. One of the

00:04:46.800 questions we received is, what is the best device to buy if you want to do zone two in your home?

00:04:53.380 Rower, stationary bike, or treadmill? Bob, or should I say Ron, may I take a step back from this before

00:05:00.960 answering it and create a bit of a broader context if there's a listener who's not familiar with exactly

00:05:06.240 what zone two is? I'll allow it. I think it'll be helpful. Thank you. As you know, in our practice,

00:05:11.700 we have kind of a framework for how we think about exercise and it has four components. Those

00:05:17.140 components are stability, strength, aerobic efficiency, and anaerobic performance. Now I will

00:05:24.120 focus on one of those today. I just want people to understand that when we talk about zone two,

00:05:29.940 it doesn't mean at the exclusion of these other things, stability, strength, and the anaerobic

00:05:35.420 piece. But it is the way in which we think through the aerobic piece. So you don't want a table that

00:05:43.180 stands on three legs or two legs or God forbid one leg any more than you want a root canal. And

00:05:50.500 therefore, one has to be very clear that when you think about zone two, you understand that it is

00:05:57.340 but one component. In subsequent episodes of both the podcast and AMAs, we'll get much deeper into

00:06:03.240 these other things. When you understand that, you understand, okay, well, zone two, it's got a very

00:06:08.080 clear definition. And this was covered in a previous podcast with Inigo San Milan. I don't remember what

00:06:12.680 number that is, but obviously we'll link to it, 85. So it is defined as basically your highest metabolic

00:06:19.680 output, the highest amount of work that you can sustain while keeping your lactate level below

00:06:28.580 two millimole or two moles per liter. So what does that mean in English? To understand that,

00:06:35.880 you have to think about what's happening biochemically as you exercise or frankly do

00:06:41.720 anything. The process of respiration, which is central to our existence, is the process of using

00:06:49.000 substrate. And for the purpose of this discussion, let's just think about glucose and fatty acids

00:06:53.860 and oxygen to make ATP and carbon dioxide. So let's just restate that. We use glucose. We use

00:07:02.500 fatty acids. We use oxygen. We undergo a chemical process. So we take the chemical energy that is

00:07:11.120 stored in the bonds of those molecules. We turn that into electrical energy. People have heard of

00:07:18.620 something called the electron transport chain, which is the bulk of where that takes place. And then it

00:07:23.320 gets turned back into chemical energy as we borrow from that energy to make ATP. And then ATP becomes

00:07:29.900 our currency for how we do everything. And just again, to put this in perspective, any interruption

00:07:36.220 in that system is fatal. So when you think about a toxin like cyanide, why does a microscopic dose of

00:07:42.900 cyanide kill somebody instantly? It's because it actually stops that process. Now, people may already

00:07:48.560 appreciate that there are a couple of different ways that we can go about making ATP. And it basically

00:07:54.220 comes down to how quickly the body is asking for it. So the first step, and let's just limit ourselves

00:08:02.460 to the discussion of glucose to make this really simple. The first step is turning glucose, which has,

00:08:07.820 it's a six carbon ring into two smaller molecules that are each made up of three carbons called

00:08:15.300 pyruvate. And that process doesn't yield a whole heck of a lot of ATP. It yields a little bit,

00:08:20.640 costs a bit, makes a bit. But when you stop there, the body kind of has a choice. And the choice is,

00:08:28.820 do I continue this process outside of the mitochondria where I make another by-product called lactate,

00:08:37.460 and I can generate a little bit more ATP, by the way, or do I take that pyruvate and shuttle it into

00:08:43.400 the mitochondria and undergo a separate chemical pathway and a separate process called the Krebs cycle

00:08:50.040 where I can make many, many more ATPs. So we'll obviously link to sort of figures that make this

00:08:56.340 much more clear graphically. But if you need to make ATP really, really quickly, you'll take that

00:09:02.020 former pathway and make lactate because you don't need oxygen to do it. So you're not limited by the

00:09:09.220 amount of oxygen that is being taken up by the muscle. If you have time on your hands, you'll take

00:09:14.800 the latter pathway, which means you will utilize oxygen and actually take that substrate into the

00:09:20.760 mitochondria and you will be able to make tons of ATP. Now, all people are not created equal, 0.83

00:09:27.220 both genetically, but more importantly, through training. And one of the biggest things that

00:09:31.680 differentiates the highly trained from the untrained, the metabolically fit from the metabolically

00:09:38.080 unfit, the flexible from the inflexible is that ability to, under a greater and greater array of

00:09:45.960 metabolic demands, make that input of substrate into the mitochondria. So mitochondrial health then

00:09:53.960 can be somewhat estimated and proxied by the ability a person has to do this. So how would you measure

00:10:00.820 this? I mean, shy of doing muscle biopsies and things, which obviously we're not going to do,

00:10:05.040 how can we get an estimation of this? And it turns out one of the most valuable ways to do this is to

00:10:13.220 measure lactate levels, because we can measure this. This lactate, if you start producing too much of it,

00:10:19.180 will actually escape the muscle and get into your circulation. And you can measure it very easily

00:10:23.780 with a finger prick, just as you would measure glucose or ketones or some other metabolite.

00:10:28.040 A healthy person, when they're sitting there at rest, has a lactate level of about one millimole.

00:10:34.880 If they get up and move about their day and walk around and have breakfast and watch TV and get in

00:10:41.580 the car or do whatever they're doing, their lactate really shouldn't be changing. They're actually

00:10:46.180 demanding more ATP than if they were sleeping, but a reasonably metabolically flexible person and

00:10:52.440 healthy person, those activities I just described shouldn't at all be pushing you to generate higher

00:10:57.700 levels of lactate. So in other words, you're not accumulating lactate. Now, what happens if we

00:11:03.840 ask you to start doing something a little more strenuous? At some point, you're going to start

00:11:08.620 generating lactate. It doesn't matter how fit a person is. If you push the fittest person on the

00:11:13.400 planet, at some point, they're going to have to start generating lactate because you're basically saying,

00:11:18.540 I need you to make energy or ATP faster than you're able to deliver oxygen to your muscles.

00:11:23.360 And at some point they can't clear that lactate. So at some point the lactate begins to accumulate

00:11:29.960 in excess of what is cleared and we can measure that. Now it's a bit more complicated because the

00:11:36.560 organ that is primarily responsible for clearing lactate is the liver and it does so via gluconeogenesis

00:11:42.020 and that takes longer. So there's a big time lag there. The other thing is different people have

00:11:47.340 different amounts at which they clear lactate from the cell. So everything I'm describing is taking

00:11:52.020 place in the cytoplasm of the cell. It still has to escape the cell to get into the circulation.

00:11:56.800 And it does so via transporters called MCTs. So different people can have different levels of

00:12:02.640 MCT expression. But if you put that aside for a moment, it's crystal clear that the fitter a person

00:12:11.380 is, the healthier a person is, the more work they can do with less lactate. And therefore for a given

00:12:16.780 individual, we use this metric of zone two as a place to say, how metabolically healthy are you?

00:12:25.720 How good are your mitochondria? And that means how much work can be done while you keep your lactate

00:12:32.260 right at about two millimole. We kind of use a slight range. We'd say about 1.7 to two millimole.

00:12:39.400 So how does one do this? So if I'm walking down the street and I run into you and I say,

00:12:45.160 hey, Bob, what's your zone two? And we were both in the know on this. You could literally spit out

00:12:50.360 a metric. You could say, oh, my zone two is 200 Watts. That would assume that you're riding a bike.

00:12:55.480 And that would mean you could hold 200 Watts for a very long period of time because you're never

00:13:01.700 really going above two millimole. And two millimole is a very, very sustainable level of lactate

00:13:08.420 production. People have probably heard the term lactate threshold. This is well below lactate threshold.

00:13:13.620 Lactate thresholds for most people kind of in the four millimole area. And at lactate threshold,

00:13:19.800 an athlete is really only able to hold that pace for, depending on their level of fitness,

00:13:25.020 we're talking tens of minutes, if not less. And obviously peak output is going to produce lactates

00:13:31.300 easily over 10. And in some cases over 20, those are, you know, efforts that can be sustained for

00:13:36.900 seconds. Sort of all out two minute effort might produce that in a very fit individual.

00:13:41.600 But zone two is functionally thought of as your all day pace, but there is an enormous variability

00:13:48.780 between what some can do and what can't. In the podcast with Inigo, we discuss one of the studies

00:13:53.860 that he did, I believe with George Brooks, where they compare people with type two diabetes to people

00:14:00.080 who are normal fit people to world-class people, world-class athletes, I believe cyclists.

00:14:05.320 And the difference in the zone two, meaning the amount of power that they could put out on a

00:14:11.180 bicycle while keeping lactate at two was staggering, especially once you normalize for weight, which is

00:14:16.940 really the way you want to normalize these things is not just how many Watts, but how many Watts per

00:14:20.700 kilo. So I know that was a bit, maybe more information than people wanted upfront, but I don't

00:14:24.840 think you can understand everything. You're probably going to want to ask me without that. So now your

00:14:28.840 question, if I recall was, if you want to do your zone two training at home, what's the best type

00:14:32.840 of device to do it on? Thank you for listening to today's sneak peek AMA episode of the drive.

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The Peter Attia Drive - January 18, 2021

#145 - AMA #19： Deep dive on Zone 2 training, magnesium supplementation, and how to engage with your doctor

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