The Peter Attia Drive - #218 - AMA #38： Can you exercise too much？

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.

00:00:31.140 So without further delay, here's today's sneak peek of the ask me anything episode.

00:00:39.240 Welcome to ask me anything episode number 38. I'm joined once again by Nick Stenson. In today's

00:00:44.620 episode, we dive in really deep to this question around exercise and if there is such thing as

00:00:49.760 too much exercise. Obviously we talk a lot about exercise on this podcast and that's for pretty

00:00:54.340 obvious reasons. Namely, it's perhaps the single most important tool we have to live longer and

00:00:59.620 live better. However, we often get asked a lot of questions about the optimal dose of exercise for

00:01:04.560 longevity. So it's a topic where there's a lot of confusion in the literature and we've even had

00:01:08.680 previous guests on the podcast who disagree with each other on what those answers ought to be with

00:01:13.580 respect to the dose of exercise. So for this AMA, we compiled all the questions that you've asked around

00:01:18.480 this and we've now taken the hard look at this. So which studies say what things, how contradictory

00:01:24.700 are the results? And we do this primarily by looking at the so-called J curve. The J curve meaning that as

00:01:30.840 you go from being sedentary to being active, your risk of all cause mortality declines. But then

00:01:36.840 something paradoxical seems to happen, which is after bottoming out, it starts to uptick again,

00:01:41.260 the so-called J, suggesting that once you go beyond a certain point, that is to say, once you exercise

00:01:47.760 beyond a certain point, your risk no longer stays low, but actually starts to go back up.

00:01:52.920 Now, this episode took a lot of time. In fact, we were going to record this episode about two

00:01:56.960 months earlier, but I just didn't feel we had done a deep enough dive. So we delayed it. And the reality

00:02:03.400 of it is there's so much here that we just can't discuss in a podcast because the podcast would be

00:02:08.720 too many hours. So what we do is we talk about everything in summary. We deep dive into a handful of

00:02:15.020 studies. We discuss some of the illustrative critiques on all sides, but really, if you want

00:02:21.340 to see this at the deepest level, I would encourage you to look through our show notes where we're going

00:02:25.760 to link to all of the analysis has been done on each of the studies. So if you're a subscriber and

00:02:30.700 you want to watch the full video of this podcast, you'll find that on the show notes page. Also,

00:02:34.680 if you're not a subscriber, you can watch a sneak peek of this on YouTube. So without further

00:02:38.260 delay, I hope you'll enjoy AMA number 38. Peter, how are you doing? I'm good, Nick. How are you?

00:02:48.620 I'm doing good, man. You ready for another AMA? Sure am. All right. Well, this one I think is on

00:02:53.280 a topic you're a little more excited about than maybe the fruits and vegetables one, looking at

00:02:58.760 exercise. So there's been no shortage of things that you've spoken about exercise and how positive

00:03:04.500 you are on it. You've often talked about how it's one of the most potent things we have

00:03:08.600 in the toolkit for longevity. And whenever you talk about it, we get a lot of questions from

00:03:14.180 subscribers. A lot of people wondering how should they think about exercise? Like what is the optimal

00:03:19.440 dose of exercise for longevity? And I think we see this anytime we do an exercise podcast because

00:03:26.300 you have your four pillars of exercise. And so people are always wondering, how do I get everything

00:03:31.220 in? How much should I be working out? I think some of the confusion can also come from past guests,

00:03:37.220 maybe having different opinions. I think when you look at the literature, it also doesn't quite agree

00:03:41.840 with each other. You know, so if you take someone like Alex Hutchinson and you take maybe the AMA you

00:03:47.060 and Bob did on VO2 max, and you talked about how important that was. And then you have a podcast like

00:03:53.380 we did with James O'Keefe where he and his research talks about a J curve. It's kind of hard for

00:03:58.440 subscribers at times to understand the literature, right? How do you get an elite VO2 max when some

00:04:05.100 of the other research says the best thing you can do is play badminton? You know, those two things

00:04:09.180 don't quite add up. And so what we did for this one is we compiled all these questions around this

00:04:15.460 to really try and answer the core question, which is what is the optimal dose of exercise for longevity?

00:04:22.160 And quick disclaimer is, we're not looking at what is the minimum dose, which I think gets written about

00:04:28.500 a lot. And I know we've done weekly emails, kind of responding to articles that are like 10,000 steps,

00:04:34.980 10 minutes of walking a day, all these little things are all you need to do. So we're going to focus on

00:04:40.400 that core question is like, what is the optimum dose? So before we get into those types of questions

00:04:46.420 that we compiled, anything you want to add to what I just said to set the stage?

00:04:51.420 Yeah, I would add that we're also going to explore, can you do too much? Because most things in biology

00:04:57.920 occupy a Goldilocks space, not too much, not too little. Clearly, that's the case with nutrition,

00:05:05.760 too much nutrition, just look around you, too little nutrition. Well, that's frankly, the problem that

00:05:10.960 lots of parts of the world still experience and have historically experienced a lot of. So

00:05:14.880 with exercise, I think that's less clear. And that's a topic we also want to really get into

00:05:20.560 today. And even if that's not relevant to the majority of the population, in other words,

00:05:25.320 even if majority of people aren't in the situation where they're butting up against potential limits

00:05:31.760 of exercise, in terms of crossing from being benefit to risk, I think it's a very important

00:05:38.900 question, nevertheless, and it might speak to some of the mechanistic insights around exercise.

00:05:43.760 And of course, for those people who do want to push the limits, it probably gives us some insight

00:05:48.300 as well.

00:05:49.340 So maybe we just start with one of the first questions. And it's something that you've covered

00:05:53.900 before, so we don't have to go into it in an insane amount of detail. But I think it might be

00:05:58.200 helpful for people just to set the stage on why they should care about this and why it's worth

00:06:02.840 putting in the time to exercise. How is exercise so beneficial, not only for our healthspan,

00:06:09.020 but also for our lifespan. And you kind of tried to summarize in a cartoon you put on Instagram

00:06:14.580 the other week at this point, which kind of looked at the guy in the doctor's office and

00:06:20.240 the doctor asked him, like, what would you rather do exercise one hour a day or be dead 24 hours a

00:06:25.960 day? And so anything that you can kind of do to set the stage on why this is so important and why

00:06:32.160 people should make the time for it should put the effort in to understand this.

00:06:36.480 To your point, I think at this point, there's really no need to spend time discussing this

00:06:42.380 beyond just stating that regardless of which chronic disease you're looking at, whether

00:06:47.820 it be ASCVD, cancer, type 2 diabetes, Alzheimer's disease, all cause mortality, it doesn't matter.

00:06:56.940 Exercise is going to reduce the toll of mortality across all of those things. The mechanisms by

00:07:03.140 which it does it can be interesting. So it can improve lipids, it can reduce inflammatory markers,

00:07:09.100 it can reduce flow-mediated shear stress in arteries. In cancer, truly, it's a little bit less

00:07:16.140 clear. I suspect much of the benefit in cancer comes through the metabolic benefits of exercise.

00:07:23.500 So we know, for example, that the second leading environmental or modifiable risk of cancer

00:07:29.620 after smoking is in fact obesity. And as I probably talked about another podcast, I think it's really

00:07:35.580 less the adiposity of obesity that's the problem and the metabolic consequences of obesity that are

00:07:41.920 found in many but not all obese patients. Obviously, diabetes is probably one of the most clear places

00:07:48.260 where you just dramatically see an improvement. And this, of course, has to do with glucose disposal and

00:07:53.520 insulin sensitivity within the muscle. And again, I think the list just goes on and on and on,

00:07:57.800 but there really isn't any ambiguity here. And again, we should sort of celebrate this fact

00:08:02.300 because there's a ton of ambiguity in a lot of things that pertain to lifespan and healthspan.

00:08:07.740 It's actually nice for once to have a slam dunk.

00:08:10.700 I think what would also be helpful for people is another term I've heard you mention before

00:08:15.500 internally as you think about your exercise and how you plot out how you tackle this problem is

00:08:21.940 METs. So do you want to let people know what a MET is and then why it can be beneficial

00:08:27.760 in looking at a variety of different exercises?

00:08:31.720 I do talk about it a little bit. And I think most people have heard of this idea of a metabolic

00:08:36.880 equivalent or a MET. And it's basically an energy currency in the body. We think about energy

00:08:43.240 currency and sort of ATP, but you know, that's on such a cellular level. This is kind of a global way

00:08:47.960 to think about it. One MET is the energy cost of being alive at rest. So obviously not a whole lot.

00:08:57.740 Worth noting that one MET is equivalent to 3.5 milliliters per minute per kilogram of oxygen

00:09:07.980 utilization. And that relationship for the most part just holds. So in other words, if you are doing

00:09:15.840 10 METs of exercise, you are consuming 35 milliliters of oxygen per minute. And that becomes

00:09:25.460 relevant as we start to think about VO2 max. Now, when you want to get a sense of what certain

00:09:31.400 activities look like, and again, so much of what we talked about on this podcast, even what we've

00:09:36.440 already gone through, like I glossed over some of the details of the benefits of exercise in the show

00:09:41.180 notes, we will include so much on that. So that if you really want to go deep on every single,

00:09:46.640 you know, aspect of health span and lifespan and the mechanism for each, we've got all of that in

00:09:51.020 great references. But again, when you want to think about how many METs do you get doing various

00:09:56.540 things? Well, again, sitting there doing nothing is one MET. Walking your dog might be three METs.

00:10:02.680 Going for a slow bike ride, kind of 10 miles an hour or less, four METs. Mowing your lawn might be

00:10:08.620 five and a half METs. Playing golf, four and a half METs. Resistance training vigorously, six METs.

00:10:15.380 So you kind of get a sense. Now, where does this go? Well, rowing at 100 watts, which really isn't

00:10:20.900 that much of a killer effort, you're at seven METs. Now you can look at the speed change, right? So

00:10:27.520 once you're running six miles an hour, which is a 10-minute mile, and that's still a jog, you're

00:10:32.820 almost at 10 METs at that point. Once you're running 10 miles an hour, six-minute mile,

00:10:38.380 this is a pace that a fit person can hold for a while, but most people couldn't hold for very

00:10:43.060 long, you're at about 14 and a half METs. So you get the sense of the non-linearity of this,

00:10:49.020 meaning 14 METs versus seven METs, you wouldn't hold seven METs for, or you wouldn't hold 14 METs

00:10:54.880 for half the time you'd hold seven METs. Just to double click on it, METs you get per activity

00:11:00.120 is per an hour of activity? No, it's all normalized per time. So if you're running a six-minute mile

00:11:06.500 pace, for an hour, we would say you did 14 and a half MET hours of work. So here's the way to

00:11:15.120 think about it. It's the difference between watts and joules, if you think about it. If anyone who's

00:11:18.660 a cyclist will think of things that way. On a bike, your power meter tells you instantaneously how much

00:11:24.680 work you're doing. That's wattage, which is really joules per second. And then you multiply that over the

00:11:31.140 total time that you do it, you take it back to total energy. So the MET is an instantaneous

00:11:37.380 measurement and you normalize it over time to give the total volume. So the work that's done

00:11:45.420 is really the MET hour. So for example, if you, I don't know, do a hike for six METs worth of activity

00:11:54.440 or six METs worth of exertion, and you do it for 45 minutes, that would be four MET hours of work

00:12:00.920 done. Peter, when people think about their METs, how is it that knowing how many MET hours you're

00:12:07.320 putting out, how is that helpful to someone as they think about exercise on a whole?

00:12:12.100 You know, look, I think for most people, it's not. Truthfully, I'm probably one of the few people

00:12:15.860 who tracks my MET hours per week. I don't do it down to the Nat's ass. I just mean, I have a 0.99

00:12:21.660 spreadsheet where I'm basically putting in my activity, the amount of time I spend doing it at

00:12:27.700 various different intensities. And I can, at the end of the week, say, look, I'm doing 100 MET hours

00:12:31.760 per week during this phase of my training. During this phase of my training, it might be 80. Back in

00:12:36.880 the old days, it was 200 MET hours per week. It was a much greater workload. If you're doing one thing

00:12:42.860 that's tied to a power meter, like in cycling, you know, we tend to keep track of kilojoules and

00:12:47.440 normalize power and power. So all of these things are just sort of ways to track the work you're

00:12:51.900 doing. Now, I think it partially becomes relevant when you want to evaluate the research because the

00:12:57.180 research has to be able to take into account not just how much time you're exercising, but what's

00:13:02.900 the intensity of that exercise. It would be very difficult to provide guidance if we didn't know

00:13:08.820 this. For example, do we want to say just the amount of distance you run a week tells us everything

00:13:16.740 we need to know? Are two people who are running 15 miles per week experiencing the same metabolic

00:13:23.500 benefit or harm? Well, certainly not. One could be running them all at 10-minute mile pace. One might

00:13:29.860 be, I mean, just imagining this, one might be running them all as 400 all-out repeats. So you have to have

00:13:37.020 some way to kind of normalize that. And in the case of the latter, you would probably see a much higher

00:13:41.800 met hour because of the intensity. And so with that kind of background, now we're going to kind

00:13:47.940 of get to the core of what we get asked about. And so the first question is, to the best of our

00:13:53.120 knowledge, are we even able to say if there is a minimum efficient or most effective dose of exercise

00:14:00.380 when you look at met hours per week? Is that something that, is that our understanding?

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The Peter Attia Drive - August 15, 2022

#218 - AMA #38： Can you exercise too much？

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