The Peter Attia Drive - #336 - AMA #68： Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more

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.

00:00:38.900 Welcome to ask me anything episode number 68. I'm once again joined by my co-host Nick Stenson.

00:00:45.080 In today's AMA, we're going to go through many of the questions you've submitted to us

00:00:48.500 through the website and summarized as a way to answer some of the most common questions that

00:00:52.980 have come through. Through this, we'll cover a wide range of topics and frameworks. We cover

00:00:57.700 topics such as how to assess cardiovascular health, including what markers to pay attention to.

00:01:02.960 Talk about intermittent fasting, including prolonged and time-restricted fasting methods,

00:01:06.940 as well as alcohol consumption and its impact on health, as well as the association with certain

00:01:11.400 diseases. Talk about nutrition, outlining the principles of a well-balanced diet, and answering

00:01:16.340 some of your questions about protein intake. We also speak about the benefits and downsides of

00:01:21.080 ketogenic diets and low-carb diets. Talk about exercise, including how to create effective

00:01:25.920 fitness routines, the importance of recovery, and we explore the topic of wearables. Lastly,

00:01:31.500 we touch on emotional health. Needless to say, this is an episode that has something for everyone.

00:01:36.720 If you're a subscriber, you can watch the video on the show notes page. And if you're not a subscriber,

00:01:41.340 you can watch a sneak peek of the video on our YouTube page.

00:01:43.660 Without further delay, I hope you enjoy AMA number 68.

00:01:53.000 Peter, welcome to another AMA. How are you doing?

00:01:55.660 Good. Thanks for having me.

00:01:57.040 Always welcome on your own show. So today, what we're going to do is we actually have gathered

00:02:02.560 all the questions over the past three or so years that people have submitted on the AMA portal.

00:02:07.960 For people who don't know, we have an AMA portal on our website where you can submit a question.

00:02:12.420 So if anyone hasn't done it, we'll link to it in the show notes. And that way,

00:02:16.680 there's questions you have that you want follow-up on, whether it's something related to something

00:02:21.380 that happened to you, questions on podcasts, newsletters, whatever it may be. And so that's

00:02:26.540 kind of what today's AMA is going to be. And we'll hit different diseases. We'll hit nutrition.

00:02:33.060 We'll hit exercise. We'll kind of hit a little bit of everything because as people can imagine,

00:02:38.000 questions came through, included a little bit of everything. So I think we'll just jump into it.

00:02:44.200 But with that being said, anything you want to add before we start with the first question?

00:02:49.500 The only thing I would add is we talked about maybe if this format, which is more questions,

00:02:55.880 less depth, more of how I would sort of answer questions if I were at a party and people were

00:03:01.760 asking me if people want more of this, but on a personal level, we've talked about accommodating

00:03:09.400 that. So maybe we just do a quarterly episode where I take very specific questions from individuals.

00:03:15.680 If they want to be acknowledged, do so and do that. So anyway, I think there's just a lot we

00:03:20.400 can play with in this format. So let's just see if folks find this helpful.

00:03:24.880 Yeah. Perfect. First question. How does someone assess their cardiovascular health? It's obviously

00:03:32.860 a topic that we've covered in such a variety of podcasts. Very important. You've often talked

00:03:38.320 about number one cause of death, not only in the U.S., but in the world. And so kind of in general

00:03:43.020 terms of someone sitting there thinking, okay, I'm curious about where I'm at cardiovascular and as

00:03:48.020 it relates to cardiovascular disease, how would you talk to them about how they can assess where they're

00:03:52.160 at? So fortunately, if somebody wants to assess their risk of cardiovascular disease, we have a

00:03:57.920 lot of tools to do it. We always start with the obvious, which is often neglected, but we should

00:04:02.720 really know our family history. It's not enough to just know my grandparents lived till such and such

00:04:08.040 an age or my aunt and uncles lived to such and such an age. Whenever possible, you really want to

00:04:12.920 understand how grandparents, parents, aunts, and uncles lived and died. And sometimes it's easier to ask

00:04:18.300 questions like, hey, did they take medication or do they take medication for cholesterol,

00:04:22.920 for blood pressure, and understanding those things. Again, some of the patterns that tend to show up

00:04:27.540 here when you see people perishing really young from cardiovascular disease, or when you see them

00:04:34.040 requiring procedures such as revascularization, stents, cabbage, things of that nature, especially at a

00:04:40.120 young age, you have to be thinking about heritable causes of ASCVD. And again, the two most common

00:04:47.160 are going to be LP little a and some form of familial hypercholesterolemia. Now the latter

00:04:53.420 is a lot easier to spot because these people have sky high cholesterol levels. The former is much more

00:05:00.860 difficult because virtually nobody is getting their LP little a tested. And so that's sometimes the

00:05:05.820 individual who themselves is kind of interested in assessing their own risk is the first to figure it

00:05:11.020 out. And then it explains what has happened over generations. So family history, very important.

00:05:17.160 Then you can sort of think about understanding, hey, has there been any damage done to date? And

00:05:22.240 here's where a calcium scan or a CAC can be a very helpful test. Now it's not a foolproof test.

00:05:28.540 It has its limitations. But if you think about the process by which damage occurs inside an artery,

00:05:34.740 one of the final stages of that is the calcification of the artery, which actually is a protective

00:05:40.040 mechanism. So the calcification of the artery per se isn't necessarily the thing that's going to kill a

00:05:46.860 person. But it's indicative of very advanced disease. And if you see calcification in one

00:05:52.860 part of an artery, it's quite likely that you have less remodeled plaque elsewhere in the coronary

00:05:59.300 artery system. And in fact, those could be the ones that are at higher risk. So again, a calcium score

00:06:03.980 in an ideal world is zero, but it's always important to remember that there's about a 15% false negative,

00:06:10.820 meaning somebody ends up with a negative CAC, calcium score zero. But in fact, if you were to

00:06:17.020 put them into a CT angiogram, which uses finer cuts of a CT and uses contrast after it does the

00:06:25.100 initial calcium score, you'll see in 15% of those cases that there is indeed some calcification and

00:06:30.480 or some soft plaque. So again, that's one more piece of information. And again, if you want to go

00:06:35.160 to a level above the CAC, then the CTA is valuable. But now you're experiencing more radiation and you

00:06:41.620 also run the risk of requiring intravenous dye or contrast, which again, it's not a major risk,

00:06:47.020 but it's non-zero. The other things I really think a person can do to assess their risk of

00:06:51.360 cardiovascular disease is obviously look at the lipid profile. So the two things we care most about

00:06:56.240 here are APOB and LP little a. And the reason for that, of course, is APOB is the aggregate marker

00:07:01.720 of all of the atherogenic proteins. Because LP little a is so disproportionately atherogenic,

00:07:08.300 you have to look at it separately because even an elevated LP little a won't show up

00:07:13.500 elevating in APOB. The good news is that you don't have to concern yourselves with LDL cholesterol,

00:07:18.880 non-HDL cholesterol, HDL cholesterol. None of those things actually matter once you know the APOB

00:07:25.060 and the LP little a. In fact, the triglyceride level itself doesn't matter unless it's dramatically

00:07:30.320 elevated sort of north of about 400 milligrams per deciliter, at which point you would actually

00:07:34.840 need to manage that as well. Another thing that I think gets so overlooked but is so important is

00:07:40.360 blood pressure. And it's just too easy to sort of go to the doctor once every two years, get your

00:07:45.480 blood pressure checked, have it come back slightly elevated, have it be attributed to white coat

00:07:50.140 hypertension, and then just sort of walk away from it. But the truth of the matter is we know

00:07:54.740 pretty unambiguously at this point that having a blood pressure below 120 over 80 is absolutely the

00:08:02.140 lowest risk and is the best way to reduce one's risk. And to be clear, that means that a blood

00:08:06.660 pressure of 130 over 85, which historically would have been considered normal, is anything but normal.

00:08:12.340 Now, the challenge with measuring blood pressure in the doctor's office is it's almost rarely done

00:08:16.440 correctly. Correctly means sitting there for five minutes, doing nothing, resting before the blood

00:08:23.000 pressure is checked. It also means having a cuff that fits correctly, having the arm at the level

00:08:28.200 of the right atrium, so about mid-chest here, not having your legs crossed when it's checked. And I

00:08:33.080 always like to check it in duplicate or triplicate. And if a person can do that twice a day for a couple

00:08:38.540 of weeks, once a year, again, not a huge inconvenience in my view, then they can have a real

00:08:43.860 assessment of their blood pressure. The other thing, of course, that's worth stating just for

00:08:48.080 completeness, though I think everybody understands it, is smoking. If you're a smoker, you're at

00:08:51.760 enormous increased risk of CVD. And of course, the same is true if you're metabolically unhealthy.

00:08:57.140 This can be anything from hyperinsulinemia all the way to insulin resistance and type 2 diabetes.

00:09:02.060 So those are really the big ones. There's a couple things I didn't include there. I don't

00:09:05.640 really look at CIMTs. I don't find them to be helpful enough. And I think the data would agree

00:09:09.920 with that. So I think that's probably 80% of risk assessment for cardiovascular disease is captured

00:09:18.500 in what I just said. If anyone wants to go deeper on any of that, as we said, we have tons of different

00:09:23.320 materials, podcast newsletters. We'll link them in the show notes for people who want to dive deeper

00:09:28.880 on any specific piece of that. But next question that gets asked a lot is, how can I use fasting

00:09:35.160 or intermittent fasting to improve my overall metabolic health? And I think a lot of times people

00:09:41.160 use those two terms, fasting, intermittent fasting interchangeably. And I know to you,

00:09:45.740 you kind of think of them a little separately. So it might be helpful to start with how you define

00:09:50.480 those two terms before then getting into how each of them can impact metabolic health.

00:09:56.100 Yeah. I think the terms fasting and intermittent fasting get used interchangeably. I'm not going

00:10:00.440 to represent that I'm the authority on any of this stuff. So I'm just going to tell you that

00:10:04.500 whatever you are talking about, just make sure the semantics are clear so that you can normalize to

00:10:10.900 what other people are saying. I typically don't use the term intermittent fasting. I use the term

00:10:16.040 fasting and I use the term time-restricted feeding or time-restricted eating to describe what I think

00:10:21.220 most people think of when they say intermittent fasting. But as a general rule, intermittent fasting

00:10:26.220 or time-restricted feeding or time-restricted eating refers to periods of not eating during the

00:10:32.340 course of a day. So when you hear people say, I do 16-8 or 18-6 intermittent fasting, of course,

00:10:39.080 what they mean is I'll go 16 hours a day without eating, 8 hours a day of eating, or 18 hours without

00:10:45.520 and 6 hours with. Fasting is a term I kind of reserve for prolonged fasts. Anything that's more

00:10:52.800 than a day, and this will easily be 2-3 days, up to really, really long fasts, 7-10 or even 14 days.

00:11:00.760 Then again, the term fasting implies that it's water only. It's non-caloric. So whatever liquids you're

00:11:07.640 getting during that period of time don't contain any calories. Okay, so now let's answer the question,

00:11:13.900 how can you use fasting or time-restricted feeding or intermittent fasting to improve metabolic health?

00:11:19.580 Well, I think the data here are not particularly clear. So I'll start with the least clear of them

00:11:27.300 all, which is the use of daily restrictions or intermittent fasting, time-restricted feeding.

00:11:32.340 The data here suggests that this type of feeding pattern is no better than straight caloric

00:11:38.580 restriction. In other words, when you normalize a person for the number of calories they consume

00:11:44.280 during a day, whether they consume those calories across the course of the day or whether they consume

00:11:49.340 those calories in kind of a small feeding window doesn't appear to have a material difference.

00:11:55.580 What does matter if a person is interested in improving their metabolic health is that they

00:12:00.180 restrict calories. And if you recall, I kind of talk about this always through the lens of three

00:12:06.880 tools that we have to reduce calories. The first is the direct way that you go about doing it. You

00:12:12.560 literally just go about counting and reducing the number of calories you consume. Again, this is the

00:12:17.480 most precise way to do it. This is why bodybuilders do it. You're not going to find a person on this

00:12:22.880 planet that is more attuned to exactly what they put in their body and how that fuel gets partitioned.

00:12:30.120 If you want an exact science, you go about counting every calorie and macro that goes in and you try to

00:12:36.080 create that offset in that way. Again, for many people, this brings a lot of overhead with it.

00:12:40.840 This brings a huge cognitive tax. And so we have two other techniques that can work quite well

00:12:47.940 indirectly. So the first is what we've just been talking about, intermittent fasting or time-restricted

00:12:52.860 feeding, where you just say, look, I don't really want to pay attention to what I eat or even how

00:12:57.340 much I eat. But if I just make the feeding window narrow enough, that has got to reduce the calories.

00:13:03.580 And indeed, it can. Not always. There's always the story of that person who in four hours a day of

00:13:09.020 eating still manages to eat 3,000 calories. But for the most part, as you restrict your feeding

00:13:14.760 window, you're going to also reduce total calories. Then the third way to go about doing this is

00:13:18.920 something called dietary restriction, which says, hey, I'm not going to concern myself with

00:13:22.200 necessarily how much I eat. I'm not going to concern myself with when I eat, but I'm going

00:13:26.220 to put in some pretty significant restrictions around what I eat. And again, the more restrictive

00:13:32.220 you are, the more you're going to end up reducing calories. So I think the most important point to

00:13:37.580 remember here is it's the calorie restriction that provides the greatest benefit. How you go about

00:13:44.260 achieving it is really a function of your style. I actually recommend people try all of these

00:13:51.080 techniques and we've covered them in so much detail elsewhere and the ins and outs of what the pros

00:13:56.160 and cons of each are, because there are many pros and cons of each. I think I dedicate a pretty

00:14:01.540 significant section of one of the chapters in Outlive to covering this. Next question on the list

00:14:07.100 relates to alcohol. And it seems like anytime we've done anything around alcohol, it seems very

00:14:13.760 polarizing, let's say. There's a lot of opinions, strong opinions on each side. And so I think the general

00:14:20.180 question is, how does alcohol affect someone's health or longevity? And how do you think about it?

00:14:27.260 There's no denying that alcohol affects our health. Alcohol is a nutrient like any other,

00:14:32.980 but it comes with some particular issues that are a little bit unique to alcohol in a way that we

00:14:38.740 wouldn't say are unique to carbohydrates, fats, and proteins. And that basically is the following.

00:14:43.820 Alcohol, in addition to being a dense source of energy, carbohydrates and proteins come with four

00:14:51.960 kilocalories approximately per gram, and fats are at about nine kilocalories per gram. Well, alcohol is

00:14:59.280 actually much closer to fats. It's at about seven kilocalories per gram. But when we're really

00:15:05.220 talking about the impact of alcohol on health, we're not even really talking about it from its caloric

00:15:10.140 standpoint. Although I can tell you, having done more food logs with more patients than I can count,

00:15:17.160 it is always amazing to see a patient's face when they recognize that 25% of their total calories come

00:15:24.140 from alcohol if they're a moderate to heavy drinker. So you don't want to be dismissive of the calories.

00:15:29.260 But I think for this question, Nick, I'm going to just put aside the caloric load of alcohol.

00:15:33.960 So what we're really talking about is the toxicity that comes from the molecule itself,

00:15:39.100 nominally through its metabolism in the liver and sort of its metabolic byproducts. Now,

00:15:45.960 we have a bit of a problem when trying to study this, which is we have to rely very,

00:15:51.600 very heavily on epidemiology. Epidemiology is, of course, one of many tools we have to understand

00:15:58.260 the impact of environmental, in this case, potentially toxins on health. But it just

00:16:03.860 comes with so much baggage. Now, again, when you're talking about an environmental toxin that is

00:16:10.380 really, really toxic, like tobacco, epidemiology turns out to be an awesome tool because the hazard

00:16:17.540 ratios are so big that it's impossible for there to be other explanations. The problem is when you're

00:16:25.480 dealing with alcohol, the hazard ratios are quite small. This is basically true of all food. And

00:16:32.640 this is why epidemiology just doesn't serve as a great substitute for randomized control trials when

00:16:40.580 it comes to understanding these things. The problem is we don't really have great RCTs around alcohol,

00:16:45.360 and the ones that we have are very short-lived. Now, we did an entire AMA on alcohol. We have an

00:16:50.480 entire premium newsletter on alcohol, so I'm not going to try to rehash all of that. So I just want

00:16:55.820 to kind of give the top-level stuff. So when you're doing these studies, one of the things you quickly

00:17:00.640 come to realize is people who abstain from alcohol for a reason, which is often where people are

00:17:07.800 abstaining from alcohol, they're either former drinkers or they have health reasons that prevent

00:17:13.540 them from drinking. There's often this paradoxical increase in mortality that we see. So if you kind of

00:17:19.000 look at some of the larger studies here, the largest one that I've seen is the recent one that came out

00:17:25.380 in JAMA last year, it included 107 cohort studies and nearly 5 million lives were studied. And it

00:17:34.100 compared a bunch of different entities to lifelong abstainers. So usually these are people who often

00:17:41.840 have religious affiliations or other reasons to have never consumed alcohol. Now, when you compare

00:17:48.160 former, former drinkers, so people who do not drink at all, but who used to drink, they have about a 26%

00:17:55.760 increase in all-cause mortality compared to lifetime abstainers. And again, that's kind of in keeping

00:18:01.800 with what I said earlier, right? Which is these are people who used to drink. They don't drink. Now,

00:18:06.060 there's usually a reason for that. Now, interestingly, when you look at the occasional,

00:18:11.740 the low volume and the medium volume drinkers, they actually didn't have an increase in all-cause

00:18:18.400 mortality. And just to put some numbers to that, occasional drinkers basically don't drink at all.

00:18:23.720 These are people that are averaging less than a drink a week. The low volume drinkers are going to

00:18:29.920 be up to a drink and a half per day. I wouldn't call that low volume, but that's how they were classified

00:18:34.940 in that study. And the medium volume drinkers were up to three drinks per day. If that's medium volume,

00:18:41.420 I need to recalibrate. But once you start to get into the high volume drinkers, these are people

00:18:46.880 that are drinking three to four drinks per day. And then the highest volume drinkers are over four

00:18:52.260 drinks per day. These people start to see an uptick in their all-cause mortality at 20 and 35%

00:18:59.540 respectively relative to the people who abstain. Now, if you look at these data and divide them by

00:19:06.220 sex, you see another thing emerge, which is that across the board, women fare worse with respect to 1.00

00:19:13.720 alcohol than men. So the first and most obvious explanation for this is simply body weight.

00:19:19.780 So if you said like women who consume 45 grams of ethanol per day versus men who consume 45 grams

00:19:26.340 of ethanol per day, of course, the women should do worse. And I do think that body weight and in 1.00

00:19:31.000 particular lean mass, because remember lean mass is where we see water and that's going to aid with

00:19:37.360 the metabolism of ethanol. That's a part of it. But we also know that women contain less alcohol 0.99

00:19:45.120 dehydrogenase, which is an enzyme that's responsible for the metabolism of alcohol. And the thinking at least

00:19:52.940 is that if women have less alcohol dehydrogenase, just genetically, then they're going to be more 1.00

00:19:58.820 susceptible to the downsides of alcohol. So I think there's a lot more we could say about this,

00:20:04.500 but the truth of the matter is when you look across the board, alcohol is associated with at least

00:20:11.560 three disease states, cardiovascular disease, dementia, and cancer, in addition to what I just

00:20:19.180 talked about, which is all cause mortality. Now, I want to point out one thing before we put this

00:20:24.200 topic to bed, which is the Mendelian randomizations typically come up with a slightly different answer

00:20:31.180 than the epidemiology. So the epidemiology usually shows kind of a flat curve for low levels of alcohol

00:20:39.360 and then a ramp up of mortality as alcohol creeps up. Different studies and different cohorts are going to

00:20:46.560 find different places. I generally tell patients that I think conservatively one drink a day

00:20:52.820 is, at least according to the epi, a minimal increase in risk. Whereas that JAMA study found

00:20:58.600 you could get up to two drinks a day, maybe even three. It was only at three when you started to see

00:21:04.040 the uptick. But the Mendelian randomization, which again is a technique where we look at genes

00:21:09.900 that control a trait. So you might look at genes that control cholesterol or genes that control,

00:21:17.540 in this case, alcohol consumption. Because again, we know that there are certain genes

00:21:22.200 that make it very difficult for people to drink alcohol. So if you believe that possessing those genes

00:21:29.500 can speak to the phenotype of drinking, and I think this is a decent example of where Mendelian

00:21:34.120 randomizations work. There are some where it doesn't. The MRs show that at any increase in

00:21:41.220 the consumption of alcohol, there is indeed an increase in mortality. So they show an increasing

00:21:47.380 level. So we say that that means that the first and second derivative are positive. So any standard

00:21:54.480 deviation and increase in the consumption of alcohol leads to a greater increase in the risk of

00:22:00.140 everything from hypertension, to dementia, to cardiovascular disease, to cancer, to all-cause

00:22:05.440 mortality. So how do we reconcile these two things? Well, I think it's kind of tough, right? Because

00:22:10.040 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

00:22:20.200 nutrient. There's nothing that it's doing that's good for you. And therefore, after that, you just have

00:22:25.320 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

00:22:34.880 sleep trackers out there, I think most people will observe that if you drink a little bit too close

00:22:39.040 to bed, your sleep is going to be disrupted. Does it change the way you eat? For example, if you have a

00:22:44.200 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

00:22:53.220 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.

00:23:03.660 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

00:23:14.300 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

00:23:29.100 friends in that environment? I don't want to dismiss the importance and the benefit of social

00:23:34.260 interaction and the joy that comes from that. I think it just comes down to the dose, truthfully.

00:23:38.420 So if that person says to me, look, twice a month, I like to meet my buddies and we like to play poker

00:23:43.560 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

00:23:53.900 understanding how the pro-social benefit of hanging out with your buddies that day justified having 12

00:23:59.940 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 related. The first one is, what do you think are the key principles for a quote unquote,

00:24:17.540 well balanced, healthy diet? Thank you for listening to today's sneak peek AMA episode of

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The Peter Attia Drive - February 17, 2025

#336 - AMA #68： Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more

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