The Peter Attia Drive - #325 ‒ Peter's key takeaways on bone health, calorie restriction and energy balance, dopamine and addiction, gene editing, and testosterone therapy safety with a prostate cancer diagnosis ｜ Quarterly Podcast Summary #3

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

00:00:15.820 I'm your host, Peter Atiyah. At the end of this short episode, I'll explain how you can access

00:00:20.280 the AMA episodes in full, along with a ton of other membership benefits we've created,

00:00:24.900 or you can learn more now by going to peteratiyahmd.com forward slash subscribe.

00:00:30.600 So without further delay, here's today's sneak peek of the ask me anything episode.

00:00:38.980 Welcome to another AMA episode of the drive. Today's episode will be the third of what we're

00:00:44.040 calling the quarterly podcast summary. The feedback again has been very positive on these. So we're

00:00:49.480 going to continue to do these. And in these conversations, what I do take the interviews

00:00:54.540 that I've done over the preceding quarter and note the most important insights that I've gained

00:01:00.280 personally from these interviews, along with any changes that have resulted in my practices

00:01:05.280 from these insights. So with all that said, these shouldn't be seen really as a replacement for

00:01:10.440 listening to these, but I hope they serve as both a primer if you've listened to them, or maybe they

00:01:15.820 direct you to go back and listen to something that you missed. In today's episode, I'm going to cover

00:01:20.540 interviews that I did with Anna Lembke, Feng Zhang, Belinda Beck, Eric Ravison, and Ted Schaefer.

00:01:27.820 In this discussion, we speak about topics such as dopamine, addictions, CRISPR, gene editing,

00:01:34.080 bone health, the importance of exercise at any age, energy balance, caloric restriction,

00:01:40.040 prostate cancer, testosterone, and much more. If you're a subscriber and you want to watch the full

00:01:45.720 video of this podcast, you can find it on the show notes page. If you're not a subscriber,

00:01:50.280 you can watch a sneak peek of the video on our YouTube page. So without further delay,

00:01:54.660 I hope you enjoy this special quarterly podcast summary AMA of The Drive.

00:02:04.900 Peter, welcome to another quarterly podcast summary AMA, which is a mouthful. How are you doing?

00:02:11.820 Good. Do we have an abbreviation for that?

00:02:13.360 I think it's QPS 1, 2, 3. This is 3.

00:02:18.820 QPS 3 AMA 60 something.

00:02:22.480 Yeah. We're just going to keep throwing numbers at it until it sticks.

00:02:25.220 That's definitely not confusing to the listener.

00:02:27.760 Well, thank you for coming to Austin to do this one in person.

00:02:30.580 Yeah. It's honestly weird to not look at you through a screen for one of these.

00:02:35.140 I feel the same way.

00:02:36.100 Yeah. I can't hide what I usually do behind the screen in this one. So this is a much more serious

00:02:40.960 episode. So for this one, as a reminder for people, because it's still relatively new,

00:02:46.520 what we're doing with these quarterly podcast summaries is we're taking previous episodes

00:02:51.140 and just going through them with your thoughts. And this came about because you take an insane

00:02:56.340 amount of notes through the podcast you have in front of you there. And so we would internally

00:03:01.040 kind of go through these and we did a few of these and people really liked them. And so

00:03:05.000 what we're going to do is we'll go through, we won't necessarily summarize them as much

00:03:09.380 as you will talk about your big takeaways. And then we'll kind of have a conversation

00:03:13.200 on how that's affected either your behavior, how you deal with patients, anything of that

00:03:18.760 nature. And so for today's episode, we're going to talk about dopamine through Anna's

00:03:23.740 podcast. We have CRISPR, which is super interesting through Fung's podcast, bone mineral

00:03:29.680 density, lifting and females, especially as you age with Belinda calorie restriction with 1.00

00:03:35.440 Eric, which is always of interest. And then prostate cancer, which was kind of a special

00:03:40.400 shorter episode we did with Ted. So I think it's really good, kind of a huge variety of things

00:03:47.960 that we'll cover. But with that said, anything you want to say before we roll?

00:03:52.700 No, just to reiterate, I'm sure I'll have said this already in the intro, which I obviously

00:03:56.480 haven't recorded yet, that this is not a substitute for going back and listening to the podcast

00:04:00.280 because I'm not even attempting to provide the full context of everything. What I'm really

00:04:04.960 trying to do is capture what I'm taking away in real time as I'm having these discussions

00:04:10.320 with people. What am I making notes on? That's effectively the filter here is what is Peter

00:04:15.960 pulling out of this as the most interesting stuff? And sometimes that comes with an assumption

00:04:22.260 that other content is understood and heard. So the hope is that you're listening to

00:04:26.300 this after you've heard these podcasts or that you listen to these and maybe go back

00:04:30.640 and listen to a podcast that you skipped because the insight is particularly interesting.

00:04:35.300 Yeah, definitely. Let's start with Anna's episode, which covered dopamine, great book,

00:04:42.040 super interesting episodes. So do you want to kind of start with what your main takeaways

00:04:46.020 were from that episode?

00:04:47.980 Yeah. So I read Anna Lemka's book, obviously before interviewing her, enjoyed it a lot and was

00:04:53.600 kind of looking forward to talking about this and had a lot of questions about what really

00:04:58.440 constitutes addiction. Because I think the book is really about addiction more than it is about

00:05:03.500 dopamine, right? Dopamine is kind of a heuristic. Everybody's heard the term dopamine. Everybody

00:05:07.500 understands what dopamine is. It's a neurotransmitter. It's one of the most important

00:05:11.980 neurotransmitters in the reward system and therefore in the addiction system, but it's not the only one.

00:05:16.540 And so I think my interest was maybe even personally a little bit less in the nuts and bolts of dopamine

00:05:21.600 and more around the science of addiction. We started with defining the traditional aspects

00:05:27.260 of what defines addiction. So the sort of out of control compulsive use, the cravings, the continued

00:05:33.320 use despite consequences, and then the tolerance to the stimulus and then ultimately withdrawal when

00:05:39.760 it's removed. So again, if you view that through the traditional lens of how people think of an

00:05:43.720 addiction like alcohol, all of those things clearly check, check, check, check, check. But of course,

00:05:47.960 there are behavioral things that show up here as well. Everything from gambling to sex to workaholism,

00:05:54.040 many of these things can constitute an addiction. Now, one of the things I took away from this that

00:05:58.640 I found interesting was the idea of what are the factors that influence this. In particular,

00:06:02.320 I wanted to really understand how heritable addiction was, meaning how much is this written

00:06:06.520 into the genetic code? Turned out quite a bit according to the heritability data. Now, again,

00:06:11.640 you'll often hear us talk about these. This came up in the podcast with Carl Deseroth, where we talked

00:06:17.560 about eating disorders, depression, schizophrenia. The typical way that these conjoint twin studies

00:06:23.380 are done is they look at the prevalence of a certain condition in identical twins that were

00:06:29.900 raised apart. That's really the best tool we have to understand how much of a role do genes play.

00:06:36.480 You take two people with identical genes raised in a completely different environment. And based on

00:06:41.440 that, Anna said that addiction is about 50 to 60% heritable. That's a huge amount, obviously,

00:06:48.840 but it's a big enough amount that it can't be ignored, but it's not so big an amount that the

00:06:53.180 die is cast. Meaning just because you come from a line of people who have an addiction to one thing or

00:06:59.580 another doesn't mean that your fate is sealed. So what are the other two things that play a role in

00:07:04.800 this? And she described them as nature, nurture, neighborhood, nature, genes, nurture, how you're

00:07:11.900 raised and neighborhood, meaning the environment you're in. Now she wasn't able to provide, or at

00:07:17.540 least if she was, I missed it, what the percent is for nurture versus neighborhood. But again, if

00:07:24.320 heritability is 50 to 60%, we're going to say 40 to 50% comes from how you were raised. And I don't

00:07:30.660 just mean like the obvious things, but I also mean the subtle things. So are you raised around people

00:07:36.140 that are engaging in a certain behavior? Do you have experiences in life, for example, trauma that

00:07:40.180 might predispose you to certain addictive behaviors? This idea of neighborhood is very important. And I

00:07:45.540 think it really has a lot to do with anybody who's ever considered trying to break a bad habit. So if

00:07:50.540 you struggle with gambling, it's really hard to break a gambling habit. If all your friends are

00:07:55.520 gamblers, you either have to get a bunch of new friends or somehow just decide you're going to hang

00:08:00.640 out with a bunch of people who gamble, but not do it yourself. Very difficult. Another topic that I

00:08:05.580 just found incredibly fascinating, and I don't think we know the answer is the takeaway is why do some

00:08:12.100 people have a certain lock and key configuration for certain addictions? So why is it, I use myself as

00:08:19.640 an example, I think in the podcast, I really enjoy alcohol. Like it's not like I'm repulsed by the

00:08:24.880 taste of alcohol. I quite enjoy it. Like literally enjoy the taste. I just don't think I could be an

00:08:29.720 alcoholic if I tried. In other words, if you surrounded me with alcoholics, it would never

00:08:34.000 appeal to me to drink in the morning or to drink in a manner that would lead to excessive use. So

00:08:39.980 why is that? It's clearly not moral superiority. That's not what I'm trying to say. It's that there

00:08:45.120 is something in my brain that doesn't get enough of that cycle from alcohol that it just doesn't work

00:08:51.120 for me that way. The same is true with gambling. I was in Vegas, remember giving a talk a little

00:08:55.320 while ago, had to walk through a casino like 25 times to and from where I was going. And again, I don't

00:09:00.960 say this to be disparaging of the people that are in casinos at seven in the morning, but I just

00:09:05.360 couldn't imagine, like if you said to me, Peter, we have a job for you. You just have to sit in the

00:09:09.480 casino and play blackjack and we'll pay you a million dollars a month to do this and cover all your

00:09:14.040 losses and you can keep all the winnings. I couldn't do it. I couldn't imagine something less

00:09:18.720 appealing. And yet there are obviously people who can ruin their lives doing this. Why?

00:09:22.960 And by the way, there are things that I'm addicted to that most people would look at and say,

00:09:26.360 who could do that? This why question, I don't think we have an answer to yet.

00:09:30.800 And yet it totally fascinates me. To me, that's the most interesting question in this space.

00:09:35.720 How does Anna work with clients? She's a psychiatrist. One of the first steps that she 1.00

00:09:39.640 thinks about, and I think this is valuable for any of us that are trying to cope with our own

00:09:43.280 addictions is she does a four week dopamine fast, which means a four week total abstinence from the 0.99

00:09:51.980 behavior that one is trying to rid themselves of. She said that 80% of her clients, her patients will

00:09:59.120 feel better after the four week fast. Now she also noted some of those people need medications to help

00:10:06.540 them through that. So for example, if a person is trying to do a dopamine fast around alcohol,

00:10:12.580 they may actually require benzodiazepines medically to help with that transition. Of course,

00:10:18.320 that's not always the case. She also talked, I think, I can't remember if this was in her book

00:10:21.840 or we talked about it, but I think we also discussed a woman that was basically smoking pot 24 seven 1.00

00:10:27.460 and was doing it because of her anxiety. But of course, turned out she was having all the anxiety

00:10:32.760 because she was smoking all the pot, but this wasn't realized until she was able to sort of abstain 0.68

00:10:36.580 from it. Okay. Another thing that I found just interesting sort of nuance was around pain and

00:10:42.880 pleasure. One of the examples we used was that of cold plunging. So people have heard me talk a lot

00:10:48.340 about cold plunging. I'm a huge fan of it, although I still firmly maintain it has no longevity benefit.

00:10:54.320 There's no gyro protective benefit of cold plunging. So to all the biohackers out there, I'm sorry, 0.99

00:11:00.000 but I don't think this is going to make you live longer. But I do think there are two distinct

00:11:04.260 benefits. I think one is a reduction in inflammation and muscle soreness. And I think the other for

00:11:10.520 select people is an improvement in mood. Anna talked about how she's tried cold plunging many times

00:11:16.180 and has never experienced an improvement in mood. And I was like, oh, that's super interesting.

00:11:20.400 I've heard many people say that, but I've heard just as many people share my experience, which is

00:11:25.800 no matter what mood I'm in, no matter how foul it is, if I get into a 40 degree bathtub, bury myself to

00:11:33.640 my neck for 10 minutes, I feel insanely good after that. And again, it's not unlike the issue we

00:11:42.020 discussed earlier of why do some people have the key go in the lock for alcohol and it's like both

00:11:48.820 thumbs up, other people don't have it. What it really comes down to is endogenous dopamine production

00:11:54.520 from pain. So Anna talked about how we live in a state of homeostasis. This is obviously a factor

00:12:02.180 spread across all of biology. So when it comes to maintaining regular glucose levels, when it comes

00:12:07.620 to maintaining a regular pH, body temperature, all of the core things that allow us to live

00:12:13.200 require homeostasis. And the body has remarkable tools for adjusting up and down to keep us in that

00:12:20.000 window. And dopamine is no exception. And so when we do something that is difficult, that induces pain,

00:12:27.880 and the two examples that she gave were cold immersion and exercise, the body has to offset 0.71

00:12:34.640 that pain somehow. And it does so by increasing the endogenous production of dopamine. What's

00:12:40.940 different about this is one, it's not a huge rush of dopamine that you get for free. It's this dopamine

00:12:46.720 that you kind of had to work for to offset something you're doing that's actually causing pain. So when you

00:12:52.780 remove the pain, your painful stimulus, i.e. when you get out of the cold plunger, when you stop the

00:12:56.980 workout, you have this lingering effect of that heightened dopamine. But again, it's a physiologic

00:13:02.720 level, and it hasn't been sort of a hijacked level. There was a line in Anna's book that she credits to

00:13:09.720 the person who said it, and I can't remember who that was, but I loved it. Our brains are like

00:13:15.300 cactuses that now reside in rainforests. So we evolved in an environment where stimulation was

00:13:24.460 relatively modest, and our brains had normal tools for coping with the up and down swings of dopamine.

00:13:31.360 And now we live in the most stimulating environment imaginable. And obviously, we just didn't have

00:13:37.000 enough time to adapt. Anybody can sort of follow the logic there. And so I think that makes a lot of

00:13:43.640 sense. And it probably speaks to kind of what I think of as the big takeaways from this. So the

00:13:49.320 big takeaways here, especially if you're a parent, is to sort of ask the question, what are we doing

00:13:55.340 to prevent our kids' brains from being hijacked by this? So even the world you and I grew up in,

00:14:02.000 more than 10 years older than you, but whether you grew up in the 70s or the 80s, we still grew up in a

00:14:06.880 relatively stimulation-free world. I mean, the most stimulating thing in my life was a cheap cathode

00:14:13.160 ray tube TV watching reruns of happy days. Like that was the pinnacle of stimulation in my life.

00:14:20.560 And today, forget about it. Kids wouldn't even know what that is if they saw it. So everything

00:14:26.380 is in technicolor. And two things she said really probably stand out. One is social media. The other

00:14:33.040 is pornography. Again, I think I brought up the example of when I was a kid, pornography was a

00:14:38.240 Playboy magazine. Today, it's VR, literally. All of this stuff, there's just no way around it.

00:14:46.160 As a parent, I think you just have to be the one that's in charge of saying,

00:14:49.080 we're going to absolutely minimize, avoid these things to the best of our ability.

00:14:54.300 I don't think there's much I would add here because so much of this is advice I think everybody

00:14:58.080 already kind of knows about how much you limit smartphones, social media, all of those things.

00:15:02.880 Those are the big takeaways from this podcast. A few follow-up questions there. First is on the

00:15:08.600 hair ability piece. So about 50 to 60%, which is large. And I know we've talked in other podcasts

00:15:13.660 about the importance of like family history and taking a detailed family history, typically as it

00:15:18.520 relates to diseases, cardiovascular disease, Alzheimer's, things of that nature, cancer. So when

00:15:24.520 you're having patients and new patients do family histories, are you now having them also include

00:15:30.680 addictions in there? Have you always done that? Yeah, it's a good question. So we don't have

00:15:35.680 dedicated questions around it, but usually we almost always come up with it just through the

00:15:41.360 detailed questioning around everything else. And the reason is it's very difficult for a person to

00:15:47.040 struggle with an addiction to alcohol or drugs and not have it creep into their health. So it's very

00:15:53.840 common that we hear uncle Jimmy, he died of heart disease when he was 60, but truth be told,

00:16:00.180 he had a real drinking problem and da, da, da, da. So yeah, we usually emerge from the family history

00:16:04.960 knowing full well, but I actually think it's a good point. I think we could be more deliberate

00:16:08.280 about it. And we obviously pay just a lot of attention to this when it comes to mental health

00:16:12.420 as well, because when you go through the family history and you see a number of family members

00:16:17.700 with mental illness, you just realize that there's a greater susceptibility as well.

00:16:21.940 Yeah. Let's talk a little bit more about cold therapy. So you do that, you mentioned for you in

00:16:25.840 particular for mood, you said that's not the case for everyone, but there is a good amount of people

00:16:30.380 who get that benefit. And so do you find for yourself, it's more of a, if you routinely do

00:16:38.460 cold plunges, it's kind of like a consistent benefit or do you ever have days where you're like,

00:16:44.220 I'm in a terrible mood. Like I need to just step away from the computer, jump in. Do you kind of

00:16:49.420 use it both ways or how do you think about that? I occasionally do use it as the total reset.

00:16:56.020 And by the way, I don't know that that even needs to be done in the most extreme version of a cold

00:17:00.740 plunge. Like I really think that having your face dipped in a bowl of cold water, I've talked about

00:17:06.240 this in the past, can stimulate the mammalian dive reflex. So you have a big enough bowl, you put your

00:17:11.820 head into it, just even just covering your face. That can, in theory, I suppose, at least trigger an

00:17:17.900 autonomic response that upregulates the parasympathetic system via the vagus nerve and

00:17:23.520 that can tone down the sympathetic system. Actually, this is a great example of coming back to

00:17:28.440 a previous podcast. So the one with Joel Jamison, where we talked about HRV, I think he did a very

00:17:32.820 good job in that podcast explaining that you don't want to think about one system being on,

00:17:38.400 one system being off between parasympathetic and sympathetic. You just really want to think about

00:17:41.760 them always both being on. And it's just a question of the balance. Are you revving one up more than the

00:17:47.720 other? You mentioned that in addition to cold therapy, Anna talked about exercise can also 0.92

00:17:53.560 be a mood stabilizer for people. Do you see that for you? Yeah, yeah, yeah. I mean, if you deprive

00:17:58.320 me from exercise, it's noticeable within a day. When you work with patients, how do you think,

00:18:04.420 because there's obviously a huge spectrum of this. Some of it can be as simple as, I'm just not going

00:18:09.420 to look at my phone an hour before bed. Other can be deep addictions. And so how do you think in

00:18:15.060 your work with patients of when you're starting to recommend, hey, let's just try these behaviors

00:18:20.600 versus let's go see a specialist to work on this in a more nuanced, detailed manner?

00:18:27.900 I think for the most part, we like to see people try to solve this on their own using neighborhood

00:18:33.960 as the tool. So what do I mean by that? If I'm sitting around holding my phone,

00:18:40.480 I'm looking at it frequently. There's no two ways about it. And by the way, I can be very good

00:18:47.080 about not looking at social media, but it's also because I don't really like social media.

00:18:52.640 But the truth of it is, if I'm sitting around and my phone is on my lap or it's in my pocket,

00:18:58.760 I'm going to be checking email. I'm going to be checking texts. I'm going to be reading

00:19:03.260 news quite often. So if I want to avoid that, I have to come up with an alternative. And that's

00:19:11.240 where my bat phone is a good alternative, right? If I'm going somewhere where I need a phone to make 1.00

00:19:16.800 phone calls, but I don't want to have anything to do, I just bring my second phone, my bat phone, 1.00

00:19:22.860 which doesn't have email on it. I don't even know the phone number. Nobody knows the phone number.

00:19:26.940 So it never gets a text message. It's basically just a device that makes calls and has podcasts

00:19:32.800 on it if I want to listen to a podcast. So that's something that I'm just going to look at less

00:19:37.300 because I fixed the neighborhood in a sense. And so I think that's sort of generally what I try to

00:19:41.960 get patients to think about is, yeah, like how do you not have your phone in your room? How do you not

00:19:46.560 have your phone with you for an hour before bed? Not because you're white knuckling it, but because

00:19:52.280 you've come up with another thing in your routine that wouldn't have a phone with you. So if you go

00:19:58.200 and do a sauna cold plunge before bed, it's easy to displace the phone. But if I say, I want you to

00:20:04.300 sit there and stare at the wall, but not have your phone, that's a tougher ask. You do archery every

00:20:09.680 now and then you go hunting. And when you do, it's basically like being off the grid. So you're

00:20:13.700 hiking, you're deep in the woods. It's not like you're kind of sitting around your house. There's no TVs.

00:20:18.800 So during those periods of time, those handful of days, do you find that not being on your phone,

00:20:24.620 not having technology, when you come back to the world, do you use it less? Is that kind of like a

00:20:30.360 natural dopamine fast or no? I wouldn't say so because I don't think it's long enough.

00:20:36.080 I do enjoy that. I just came back from a trip a little while ago where we were bow hunting in a

00:20:41.900 very, very remote area. So there was no wifi. There's no cell service. My phone didn't work once except

00:20:48.580 for the one place where one guy had one of those little Starlink things. Once or twice a day,

00:20:53.760 you could make a phone call or something. Yeah. Everything about that is cool, which you don't

00:20:57.540 have to be hunting to do it, that you could just be camping in the right spot. But everything about

00:21:01.240 waking up super, super early, going to bed once the sun goes down and not being inundated with

00:21:07.800 anything was great. And so I don't think that would constitute a fast because at least in my case,

00:21:13.340 it's not nearly long enough, but it's enjoyable nonetheless. It also probably maybe made me feel

00:21:18.700 a bit better in knowing that I guess I don't have an addiction to that at least because I also didn't

00:21:22.980 experience withdrawal. I was like quite happy to not have the device. Awesome. Let's move on to the

00:21:29.460 next one, which is Fung's podcast, heavily on CRISPR gene editing, really interesting episode,

00:21:37.000 pretty technical at times, but also it's a topic I feel it's talked about so much. You hear CRISPR,

00:21:42.680 you hear gene editing. We've written about PCSK9, gene editing, and how that can have an impact on

00:21:48.320 cardiovascular disease. So do you want to talk about your biggest takeaways, insights you learned

00:21:53.500 from that? Thank you for listening to today's sneak peek AMA episode of The Drive. If you're

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00:24:46.600 companies I invest in or advise, please visit peteratiamd.com forward slash about where I keep an up-to-date

00:24:54.560 and active list of all disclosures.

The Peter Attia Drive - November 11, 2024

#325 ‒ Peter's key takeaways on bone health, calorie restriction and energy balance, dopamine and addiction, gene editing, and testosterone therapy safety with a prostate cancer diagnosis ｜ Quarterly Podcast Summary #3

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