#336 - AMA #68： Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
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Summary
In this episode of Ask Me Anything, co-hosts Nick Stenson and Peter Atiyah discuss how to assess your cardiovascular health, including what markers to pay attention to, how to prevent cardiovascular disease, and how to manage emotional health.
Transcript
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Hey everyone, welcome to a sneak peek, ask me anything or AMA episode of the drive podcast.
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I'm your host, Peter Atiyah. At the end of this short episode, I'll explain how you can access
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the AMA episodes in full, along with a ton of other membership benefits we've created,
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or you can learn more now by going to peteratiyahmd.com forward slash subscribe.
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So without further delay, here's today's sneak peek of the ask me anything episode.
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Welcome to ask me anything episode number 68. I'm once again joined by my co-host Nick Stenson.
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In today's AMA, we're going to go through many of the questions you've submitted to us
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through the website and summarized as a way to answer some of the most common questions that
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have come through. Through this, we'll cover a wide range of topics and frameworks. We cover
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topics such as how to assess cardiovascular health, including what markers to pay attention to.
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Talk about intermittent fasting, including prolonged and time-restricted fasting methods,
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as well as alcohol consumption and its impact on health, as well as the association with certain
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diseases. Talk about nutrition, outlining the principles of a well-balanced diet, and answering
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some of your questions about protein intake. We also speak about the benefits and downsides of
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ketogenic diets and low-carb diets. Talk about exercise, including how to create effective
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fitness routines, the importance of recovery, and we explore the topic of wearables. Lastly,
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we touch on emotional health. Needless to say, this is an episode that has something for everyone.
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If you're a subscriber, you can watch the video on the show notes page. And if you're not a subscriber,
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you can watch a sneak peek of the video on our YouTube page.
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Without further delay, I hope you enjoy AMA number 68.
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Peter, welcome to another AMA. How are you doing?
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Always welcome on your own show. So today, what we're going to do is we actually have gathered
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all the questions over the past three or so years that people have submitted on the AMA portal.
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For people who don't know, we have an AMA portal on our website where you can submit a question.
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So if anyone hasn't done it, we'll link to it in the show notes. And that way,
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there's questions you have that you want follow-up on, whether it's something related to something
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that happened to you, questions on podcasts, newsletters, whatever it may be. And so that's
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kind of what today's AMA is going to be. And we'll hit different diseases. We'll hit nutrition.
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We'll hit exercise. We'll kind of hit a little bit of everything because as people can imagine,
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questions came through, included a little bit of everything. So I think we'll just jump into it.
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But with that being said, anything you want to add before we start with the first question?
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The only thing I would add is we talked about maybe if this format, which is more questions,
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less depth, more of how I would sort of answer questions if I were at a party and people were
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asking me if people want more of this, but on a personal level, we've talked about accommodating
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that. So maybe we just do a quarterly episode where I take very specific questions from individuals.
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If they want to be acknowledged, do so and do that. So anyway, I think there's just a lot we
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can play with in this format. So let's just see if folks find this helpful.
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Yeah. Perfect. First question. How does someone assess their cardiovascular health? It's obviously
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a topic that we've covered in such a variety of podcasts. Very important. You've often talked
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about number one cause of death, not only in the U.S., but in the world. And so kind of in general
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terms of someone sitting there thinking, okay, I'm curious about where I'm at cardiovascular and as
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it relates to cardiovascular disease, how would you talk to them about how they can assess where they're
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at? So fortunately, if somebody wants to assess their risk of cardiovascular disease, we have a
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lot of tools to do it. We always start with the obvious, which is often neglected, but we should
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really know our family history. It's not enough to just know my grandparents lived till such and such
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an age or my aunt and uncles lived to such and such an age. Whenever possible, you really want to
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understand how grandparents, parents, aunts, and uncles lived and died. And sometimes it's easier to ask
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questions like, hey, did they take medication or do they take medication for cholesterol,
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for blood pressure, and understanding those things. Again, some of the patterns that tend to show up
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here when you see people perishing really young from cardiovascular disease, or when you see them
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requiring procedures such as revascularization, stents, cabbage, things of that nature, especially at a
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young age, you have to be thinking about heritable causes of ASCVD. And again, the two most common
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are going to be LP little a and some form of familial hypercholesterolemia. Now the latter
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is a lot easier to spot because these people have sky high cholesterol levels. The former is much more
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difficult because virtually nobody is getting their LP little a tested. And so that's sometimes the
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individual who themselves is kind of interested in assessing their own risk is the first to figure it
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out. And then it explains what has happened over generations. So family history, very important.
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Then you can sort of think about understanding, hey, has there been any damage done to date? And
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here's where a calcium scan or a CAC can be a very helpful test. Now it's not a foolproof test.
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It has its limitations. But if you think about the process by which damage occurs inside an artery,
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one of the final stages of that is the calcification of the artery, which actually is a protective
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mechanism. So the calcification of the artery per se isn't necessarily the thing that's going to kill a
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person. But it's indicative of very advanced disease. And if you see calcification in one
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part of an artery, it's quite likely that you have less remodeled plaque elsewhere in the coronary
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artery system. And in fact, those could be the ones that are at higher risk. So again, a calcium score
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in an ideal world is zero, but it's always important to remember that there's about a 15% false negative,
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meaning somebody ends up with a negative CAC, calcium score zero. But in fact, if you were to
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put them into a CT angiogram, which uses finer cuts of a CT and uses contrast after it does the
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initial calcium score, you'll see in 15% of those cases that there is indeed some calcification and
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or some soft plaque. So again, that's one more piece of information. And again, if you want to go
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to a level above the CAC, then the CTA is valuable. But now you're experiencing more radiation and you
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also run the risk of requiring intravenous dye or contrast, which again, it's not a major risk,
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but it's non-zero. The other things I really think a person can do to assess their risk of
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cardiovascular disease is obviously look at the lipid profile. So the two things we care most about
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here are APOB and LP little a. And the reason for that, of course, is APOB is the aggregate marker
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of all of the atherogenic proteins. Because LP little a is so disproportionately atherogenic,
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you have to look at it separately because even an elevated LP little a won't show up
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elevating in APOB. The good news is that you don't have to concern yourselves with LDL cholesterol,
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non-HDL cholesterol, HDL cholesterol. None of those things actually matter once you know the APOB
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and the LP little a. In fact, the triglyceride level itself doesn't matter unless it's dramatically
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elevated sort of north of about 400 milligrams per deciliter, at which point you would actually
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need to manage that as well. Another thing that I think gets so overlooked but is so important is
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blood pressure. And it's just too easy to sort of go to the doctor once every two years, get your
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blood pressure checked, have it come back slightly elevated, have it be attributed to white coat
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hypertension, and then just sort of walk away from it. But the truth of the matter is we know
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pretty unambiguously at this point that having a blood pressure below 120 over 80 is absolutely the
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lowest risk and is the best way to reduce one's risk. And to be clear, that means that a blood
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pressure of 130 over 85, which historically would have been considered normal, is anything but normal.
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Now, the challenge with measuring blood pressure in the doctor's office is it's almost rarely done
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correctly. Correctly means sitting there for five minutes, doing nothing, resting before the blood
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pressure is checked. It also means having a cuff that fits correctly, having the arm at the level
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of the right atrium, so about mid-chest here, not having your legs crossed when it's checked. And I
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always like to check it in duplicate or triplicate. And if a person can do that twice a day for a couple
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of weeks, once a year, again, not a huge inconvenience in my view, then they can have a real
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assessment of their blood pressure. The other thing, of course, that's worth stating just for
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completeness, though I think everybody understands it, is smoking. If you're a smoker, you're at
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enormous increased risk of CVD. And of course, the same is true if you're metabolically unhealthy.
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This can be anything from hyperinsulinemia all the way to insulin resistance and type 2 diabetes.
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So those are really the big ones. There's a couple things I didn't include there. I don't
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really look at CIMTs. I don't find them to be helpful enough. And I think the data would agree
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with that. So I think that's probably 80% of risk assessment for cardiovascular disease is captured
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in what I just said. If anyone wants to go deeper on any of that, as we said, we have tons of different
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materials, podcast newsletters. We'll link them in the show notes for people who want to dive deeper
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on any specific piece of that. But next question that gets asked a lot is, how can I use fasting
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or intermittent fasting to improve my overall metabolic health? And I think a lot of times people
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use those two terms, fasting, intermittent fasting interchangeably. And I know to you,
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you kind of think of them a little separately. So it might be helpful to start with how you define
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those two terms before then getting into how each of them can impact metabolic health.
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Yeah. I think the terms fasting and intermittent fasting get used interchangeably. I'm not going
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to represent that I'm the authority on any of this stuff. So I'm just going to tell you that
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whatever you are talking about, just make sure the semantics are clear so that you can normalize to
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what other people are saying. I typically don't use the term intermittent fasting. I use the term
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fasting and I use the term time-restricted feeding or time-restricted eating to describe what I think
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most people think of when they say intermittent fasting. But as a general rule, intermittent fasting
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or time-restricted feeding or time-restricted eating refers to periods of not eating during the
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course of a day. So when you hear people say, I do 16-8 or 18-6 intermittent fasting, of course,
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what they mean is I'll go 16 hours a day without eating, 8 hours a day of eating, or 18 hours without
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and 6 hours with. Fasting is a term I kind of reserve for prolonged fasts. Anything that's more
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than a day, and this will easily be 2-3 days, up to really, really long fasts, 7-10 or even 14 days.
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Then again, the term fasting implies that it's water only. It's non-caloric. So whatever liquids you're
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getting during that period of time don't contain any calories. Okay, so now let's answer the question,
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how can you use fasting or time-restricted feeding or intermittent fasting to improve metabolic health?
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Well, I think the data here are not particularly clear. So I'll start with the least clear of them
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all, which is the use of daily restrictions or intermittent fasting, time-restricted feeding.
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The data here suggests that this type of feeding pattern is no better than straight caloric
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restriction. In other words, when you normalize a person for the number of calories they consume
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during a day, whether they consume those calories across the course of the day or whether they consume
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those calories in kind of a small feeding window doesn't appear to have a material difference.
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What does matter if a person is interested in improving their metabolic health is that they
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restrict calories. And if you recall, I kind of talk about this always through the lens of three
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tools that we have to reduce calories. The first is the direct way that you go about doing it. You
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literally just go about counting and reducing the number of calories you consume. Again, this is the
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most precise way to do it. This is why bodybuilders do it. You're not going to find a person on this
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planet that is more attuned to exactly what they put in their body and how that fuel gets partitioned.
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If you want an exact science, you go about counting every calorie and macro that goes in and you try to
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create that offset in that way. Again, for many people, this brings a lot of overhead with it.
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This brings a huge cognitive tax. And so we have two other techniques that can work quite well
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indirectly. So the first is what we've just been talking about, intermittent fasting or time-restricted
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feeding, where you just say, look, I don't really want to pay attention to what I eat or even how
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much I eat. But if I just make the feeding window narrow enough, that has got to reduce the calories.
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And indeed, it can. Not always. There's always the story of that person who in four hours a day of
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eating still manages to eat 3,000 calories. But for the most part, as you restrict your feeding
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window, you're going to also reduce total calories. Then the third way to go about doing this is
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something called dietary restriction, which says, hey, I'm not going to concern myself with
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necessarily how much I eat. I'm not going to concern myself with when I eat, but I'm going
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to put in some pretty significant restrictions around what I eat. And again, the more restrictive
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you are, the more you're going to end up reducing calories. So I think the most important point to
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remember here is it's the calorie restriction that provides the greatest benefit. How you go about
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achieving it is really a function of your style. I actually recommend people try all of these
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techniques and we've covered them in so much detail elsewhere and the ins and outs of what the pros
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and cons of each are, because there are many pros and cons of each. I think I dedicate a pretty
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significant section of one of the chapters in Outlive to covering this. Next question on the list
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relates to alcohol. And it seems like anytime we've done anything around alcohol, it seems very
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polarizing, let's say. There's a lot of opinions, strong opinions on each side. And so I think the general
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question is, how does alcohol affect someone's health or longevity? And how do you think about it?
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There's no denying that alcohol affects our health. Alcohol is a nutrient like any other,
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but it comes with some particular issues that are a little bit unique to alcohol in a way that we
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wouldn't say are unique to carbohydrates, fats, and proteins. And that basically is the following.
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Alcohol, in addition to being a dense source of energy, carbohydrates and proteins come with four
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kilocalories approximately per gram, and fats are at about nine kilocalories per gram. Well, alcohol is
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actually much closer to fats. It's at about seven kilocalories per gram. But when we're really
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talking about the impact of alcohol on health, we're not even really talking about it from its caloric
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standpoint. Although I can tell you, having done more food logs with more patients than I can count,
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it is always amazing to see a patient's face when they recognize that 25% of their total calories come
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from alcohol if they're a moderate to heavy drinker. So you don't want to be dismissive of the calories.
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But I think for this question, Nick, I'm going to just put aside the caloric load of alcohol.
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So what we're really talking about is the toxicity that comes from the molecule itself,
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nominally through its metabolism in the liver and sort of its metabolic byproducts. Now,
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we have a bit of a problem when trying to study this, which is we have to rely very,
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very heavily on epidemiology. Epidemiology is, of course, one of many tools we have to understand
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the impact of environmental, in this case, potentially toxins on health. But it just
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comes with so much baggage. Now, again, when you're talking about an environmental toxin that is
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really, really toxic, like tobacco, epidemiology turns out to be an awesome tool because the hazard
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ratios are so big that it's impossible for there to be other explanations. The problem is when you're
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dealing with alcohol, the hazard ratios are quite small. This is basically true of all food. And
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this is why epidemiology just doesn't serve as a great substitute for randomized control trials when
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it comes to understanding these things. The problem is we don't really have great RCTs around alcohol,
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and the ones that we have are very short-lived. Now, we did an entire AMA on alcohol. We have an
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entire premium newsletter on alcohol, so I'm not going to try to rehash all of that. So I just want
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to kind of give the top-level stuff. So when you're doing these studies, one of the things you quickly
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come to realize is people who abstain from alcohol for a reason, which is often where people are
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abstaining from alcohol, they're either former drinkers or they have health reasons that prevent
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them from drinking. There's often this paradoxical increase in mortality that we see. So if you kind of
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look at some of the larger studies here, the largest one that I've seen is the recent one that came out
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in JAMA last year, it included 107 cohort studies and nearly 5 million lives were studied. And it
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compared a bunch of different entities to lifelong abstainers. So usually these are people who often
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have religious affiliations or other reasons to have never consumed alcohol. Now, when you compare
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former, former drinkers, so people who do not drink at all, but who used to drink, they have about a 26%
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increase in all-cause mortality compared to lifetime abstainers. And again, that's kind of in keeping
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with what I said earlier, right? Which is these are people who used to drink. They don't drink. Now,
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there's usually a reason for that. Now, interestingly, when you look at the occasional,
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the low volume and the medium volume drinkers, they actually didn't have an increase in all-cause
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mortality. And just to put some numbers to that, occasional drinkers basically don't drink at all.
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These are people that are averaging less than a drink a week. The low volume drinkers are going to
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be up to a drink and a half per day. I wouldn't call that low volume, but that's how they were classified
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in that study. And the medium volume drinkers were up to three drinks per day. If that's medium volume,
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I need to recalibrate. But once you start to get into the high volume drinkers, these are people
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that are drinking three to four drinks per day. And then the highest volume drinkers are over four
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drinks per day. These people start to see an uptick in their all-cause mortality at 20 and 35%
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respectively relative to the people who abstain. Now, if you look at these data and divide them by
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sex, you see another thing emerge, which is that across the board, women fare worse with respect to
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alcohol than men. So the first and most obvious explanation for this is simply body weight.
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So if you said like women who consume 45 grams of ethanol per day versus men who consume 45 grams
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of ethanol per day, of course, the women should do worse. And I do think that body weight and in
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particular lean mass, because remember lean mass is where we see water and that's going to aid with
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the metabolism of ethanol. That's a part of it. But we also know that women contain less alcohol
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dehydrogenase, which is an enzyme that's responsible for the metabolism of alcohol. And the thinking at least
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is that if women have less alcohol dehydrogenase, just genetically, then they're going to be more
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susceptible to the downsides of alcohol. So I think there's a lot more we could say about this,
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but the truth of the matter is when you look across the board, alcohol is associated with at least
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three disease states, cardiovascular disease, dementia, and cancer, in addition to what I just
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talked about, which is all cause mortality. Now, I want to point out one thing before we put this
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topic to bed, which is the Mendelian randomizations typically come up with a slightly different answer
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than the epidemiology. So the epidemiology usually shows kind of a flat curve for low levels of alcohol
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and then a ramp up of mortality as alcohol creeps up. Different studies and different cohorts are going to
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find different places. I generally tell patients that I think conservatively one drink a day
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is, at least according to the epi, a minimal increase in risk. Whereas that JAMA study found
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you could get up to two drinks a day, maybe even three. It was only at three when you started to see
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the uptick. But the Mendelian randomization, which again is a technique where we look at genes
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that control a trait. So you might look at genes that control cholesterol or genes that control,
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in this case, alcohol consumption. Because again, we know that there are certain genes
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that make it very difficult for people to drink alcohol. So if you believe that possessing those genes
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can speak to the phenotype of drinking, and I think this is a decent example of where Mendelian
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randomizations work. There are some where it doesn't. The MRs show that at any increase in
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the consumption of alcohol, there is indeed an increase in mortality. So they show an increasing
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level. So we say that that means that the first and second derivative are positive. So any standard
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deviation and increase in the consumption of alcohol leads to a greater increase in the risk of
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everything from hypertension, to dementia, to cardiovascular disease, to cancer, to all-cause
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mortality. So how do we reconcile these two things? Well, I think it's kind of tough, right? Because
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neither technique is perfect. But I think we sort of have to suggest that the precautionary
00:22:15.960
principle here would be to obviously not consume alcohol at all, because it's not an essential
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nutrient. There's nothing that it's doing that's good for you. And therefore, after that, you just have
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to be kind of judicious in your use. And you have to ask the question like, is this being
00:22:29.500
maladaptive for my life in any other way? Does it, for example, impair my sleep? With the ubiquity of
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sleep trackers out there, I think most people will observe that if you drink a little bit too close
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to bed, your sleep is going to be disrupted. Does it change the way you eat? For example, if you have a
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drink or two in you, are you more likely to raid the pantry or the freezer and get ice cream? And then
00:22:48.680
of course, there's the much more destructive stuff like driving and things of that nature. So I think
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overall, we can say that alcohol is under no dose helpful, under low doses, probably not
00:22:59.320
terribly bad, but under escalating doses, it's actually quite negative.
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How would you respond to a patient who says something in the following, which is what you
00:23:07.980
kind of see a lot, which is, I understand that alcohol may not be good for me, but I do get a
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lot of enjoyment having a drink with some friends every other week or once in a while. Do you think
00:23:20.940
that the danger of having a little bit of alcohol outweighs the potential enjoyment of being with
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friends in that environment? I don't want to dismiss the importance and the benefit of social
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interaction and the joy that comes from that. I think it just comes down to the dose, truthfully.
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So if that person says to me, look, twice a month, I like to meet my buddies and we like to play poker
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or we like to watch football and we have a few drinks, at the surface, there doesn't seem anything wrong
00:23:48.280
with that. But look, if the answer is twice a month, I'm just going to drink 12 beers. I have a hard time
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understanding how the pro-social benefit of hanging out with your buddies that day justified having 12
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beers. If the answer is, I like to kick back three or four beers a couple of times a month, then I would
00:24:05.700
say, yeah, it's probably not that bad. Moving on to the next set of questions, kind of nutrition
00:24:11.080
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