The Peter Attia Drive - March 03, 2025


#338 ‒ Peter's takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training ｜ Quarterly Podcast Summary #4

Topics
hyperbolic endurance performance VO2 max training protocol interval training pain curve VO2 max
Hosted by
Peter Attia
Guests
Quarterly Podcast Summary
Mentioned
Olav Ralph DeFranzo Mike Istratel SGLT2 Trenna Sutcliffe Alex Hutchinson Alexander Boo Sam Sutaria Ironman Gustav
#337 - Insulin resistance masterclass： The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment ｜ Ralph DeFronzo, M.D. #339 - Unpacking trauma： How early wounds shape behavior and the path toward healing ｜ Jeff English

Episode Stats


Length

27 minutes

Words per minute

186.94

Word count

5,158

Sentence count

308

Harmful content

Toxicity

1

sentences flagged


Summary

Summaries generated with gmurro/bart-large-finetuned-filtered-spotify-podcast-summ .

In this episode, I discuss what I learned from the last quarter of interviews, and what I think were some of the most important insights, as well as things that have resulted in a change in my work and behavior. Please note that I do not think listening to the quarterly podcast summary even remotely constitutes a substitute for listening the actual episodes. My hope is that it basically helps you think about refining what you might have learned there, and if something you hear in one of these summaries is of interest, I hope you go back and listen to it.

Transcript

Transcript generated with Whisper (turbo).
Toxicity classifications generated with s-nlp/roberta_toxicity_classifier .
Topics generated with Qwen2.5-3B-Instruct.
Hosts, guests, and mentioned names generated with spaCy (en_core_web_sm), reconciled against Wikidata.
00:00:00.000 Hey everyone, welcome to a sneak peek, ask me anything or AMA episode of the drive podcast.
00:00:16.320 I'm your host, Peter Atiyah. At the end of this short episode, I'll explain how you can access
00:00:20.780 the AMA episodes in full, along with a ton of other membership benefits we've created,
00:00:25.400 or you can learn more now by going to peteratiyahmd.com forward slash subscribe.
00:00:31.100 So without further delay, here's today's sneak peek of the ask me anything episode.
00:00:39.400 Welcome to another special AMA episode of the drive. Today's episode will be the fourth
00:00:44.360 installment of the quarterly podcast summary. In this conversation, I discuss what I learned
00:00:49.540 from the last quarter of interviews and what I think were some of the most important insights,
00:00:53.520 as well as things that have resulted in a change in my work and behavior. Please note that I do not
00:01:00.080 think listening to the quarterly podcast summary even remotely constitutes a substitute for listening
00:01:06.200 to the actual episodes. My hope is that it basically helps you think about refining what you might have
00:01:12.120 learned there. And if something you hear in one of these summaries is of interest and you missed the
00:01:17.400 original episode, I hope you'll go back and listen to it. In today's episode, we cover the interviews
00:01:22.040 that I did with Olav, Alexander Boo, Ralph DeFranzo, Sam Sutaria, Trenna Sutcliffe, and Mike Istratel.
00:01:30.980 And throughout these, we talk on various topics, VO2 max, power at VO2 max, insulin resistance,
00:01:37.160 metformin, SGLT2 inhibitors, GLP-1 agonists, U.S. healthcare costs, diagnosis and treatment approaches
00:01:43.840 to autism, ADHD and anxiety, zone 2 resistance training, and learning all of the effects of
00:01:52.280 anabolic steroids. And yeah, that sounds like a hodgepodge of topics, but that's because it's
00:01:56.800 pulled from all of these discussions. If you're a subscriber and you want to watch the full video of
00:02:01.580 this podcast, you can find it on our show notes page. If you're not a subscriber, you can watch the
00:02:06.740 sneak peek of the video on our YouTube page. So without further delay, I hope you enjoy this special
00:02:11.520 quarterly podcast summary AMA of The Drive. Peter, thanks for joining us on another AMA
00:02:22.440 on your own podcast. We appreciate you coming by. I always appreciate being here. Thank you for
00:02:26.800 having me. Anytime, anytime. So today is going to be another quarterly podcast summary episode. A lot
00:02:33.940 of words. Basically what it means is we look at past episodes, cover what the main takeaways are,
00:02:39.800 what your favorite insights were, any changes you made based on behavior to yourself, how you work
00:02:45.920 with patients, how you think about things, anything of that nature from those episodes. The other thing
00:02:51.420 to say as a reminder, it's meant as more to augment the episodes, not necessarily as a replacement.
00:02:57.480 And we get a lot of feedback where people will listen to this and then re-listen to some of the
00:03:01.700 original episodes and find a lot of value in it. Today, we'll look at Olav, talking about training,
00:03:08.260 performance, VO2 max. Ralph, looking at insulin resistance, type 2 diabetes, metformin, SGLT2
00:03:14.900 inhibitors, other drugs. SOM, looking at healthcare, trying to understand why healthcare in the U.S.
00:03:21.000 is nearly two times per capita of any other developed nation. Trenna, looking at autism, ADHD,
00:03:27.280 anxiety. We have Mike looking at resistance training and kind of diving into everything
00:03:33.680 revolving that. So huge variety of topics, a lot of different things that I think people should find
00:03:39.400 interest in. And I think we'll get it started with Olav. So do you kind of want to start going
00:03:45.800 through your episode with Olav? This was obviously the second time he was back on, a little behind
00:03:50.440 the scenes. We talked beforehand about, hey, let's try and make it a little less technical because the
00:03:55.460 first one was pretty technical. And I think looking back, you probably made it more technical in the
00:04:00.440 first. So I think that's just by nature how you and Olav are always going to be. So maybe break down
00:04:06.040 for people what you learned and what your biggest insights were from that. Yeah. And before we dive
00:04:11.160 into this, at least in as long as we've been doing quarterly podcast summaries, I will say this might
00:04:16.060 end up being the longest because just by the nature of coincidence and which podcasts fall into the
00:04:22.160 past quarter, this is probably the most voluminous set of notes I've ever taken across a set of
00:04:28.220 podcasts. In fact, I would say that two of the episodes that we've covered here, the one with
00:04:33.560 Ralph and the one with Psalm, were easily three to four X the volume of notes I normally take.
00:04:40.720 Impute from that what you will. I've done my best to try to synthesize that. But nevertheless,
00:04:45.940 there's a lot going on in this past quarter. Okay. You're right. I wanted to make the Olav one at the
00:04:50.900 outset just straight into less technical things. And I could not resist the tractor pull of trying
00:04:58.840 to at least explain some technical things. So we started the discussion by explaining the
00:05:03.480 difference between things like functional threshold power and critical power. I hesitate to bring these
00:05:08.580 up now because I just don't think they're relevant unless you are a cyclist. But if you are interested,
00:05:14.580 I'll just state it. The functional threshold power or FTP is the power that you can hold for one hour.
00:05:20.900 That is one way to test it. You literally get on a bike, usually on an ERG. So it's a stationary bike
00:05:26.300 and you ride as hard as you can without blowing up for one hour. And whatever the average power is
00:05:32.100 that you held as your FTP, much more typically, for example, when I was a cyclist, we would do this
00:05:37.480 in a 20 minute test and we would discount it by typically 10%, although Olav suggested only 5%. In my
00:05:44.380 experience, 10% was necessary. There's something called critical power, which is very similar,
00:05:49.900 but rather than it being the power you can hold for an hour, it's the power you can hold for 30 to 40
00:05:54.340 minutes. I think the more important distinction here is that you can calculate critical power much
00:05:59.880 easier. You can do it from a set of curves that are derived from three to four individual tests that
00:06:08.700 are much shorter. Why is this relevant? This is relevant because if you want to have other metrics
00:06:15.340 beyond VO2 max for higher end aerobic efficiency, you might want to know your FTP or critical power
00:06:23.200 and critical power is much easier to measure. So these days, and this ties into another insight,
00:06:29.300 by the way, these days, I don't spend a lot of time worrying about my FTP. In fact, I don't know what
00:06:33.040 it is because I haven't done a 20 minute power test since NAMM. Don't necessarily think I'm going
00:06:37.620 to do one anytime soon, probably because I don't want to see how low it is, but it made me realize
00:06:42.380 maybe I ought to do a critical power test just so that I have another benchmark to be tracking.
00:06:49.220 So we talked about a few other things, which I'm not going to go into anaerobic threshold and stuff.
00:06:52.860 We covered a little bit of that in the first podcast. Another very interesting insight that came up
00:06:57.860 for me in this podcast, which was really just a personal insight, and I hesitate to spend too much
00:07:01.820 time on it, was talking about the relationship between VO2 max and PVO2 max or VVO2 max. So if
00:07:08.440 you're a cyclist, what does that mean? PVO2 max means what is your power when you are at VO2 max?
00:07:15.960 Again, VO2 max, just to make sure everybody knows what I'm talking about. This is maximum ventilation,
00:07:20.280 meaning maximum oxygen consumption. It's usually sustained for at least a minute when you're doing
00:07:25.160 the test. So what's the highest amount of oxygen in liters per minute that can be consumed
00:07:29.280 for a minute. And this is achieved during a ramp exercise, almost exclusively done on a bike or
00:07:36.840 on a treadmill, stationary bike. And when you hit that VO2 max, if you're on a treadmill,
00:07:41.820 you will note that, hey, there's a velocity, assuming you're running flat, or you might see,
00:07:45.900 oh, actually I'm on a bike and my PVO2 max is the power that I've achieved. Now, some have argued
00:07:52.040 that VVO2 max or PVO2 max are actually more predictive of sports specific performance than
00:07:59.300 just the number VO2 max. And I think there might be something to that because I shared my numbers with
00:08:05.860 Olaf. And the truth of it is, I have always had a very low PVO2 max to VO2 max. Stated another way,
00:08:15.160 I have always had a VO2 max that is higher than many people who are much better cyclists than me.
00:08:22.240 It wasn't uncommon when I was training that my VO2 max was 15 points higher than people
00:08:28.200 who had a higher FTP than me, for example. And what Olaf suggested there is it speaks to
00:08:33.820 really inefficient, probably over-training aerobically, under-training anaerobically.
00:08:38.800 So there's an inefficiency there. And that inefficiency means that I am actually requiring
00:08:45.160 more energy across the board to put out more power. Now, something very interesting that comes
00:08:51.000 from that is there might be an association between people like that and a lesser propensity to gain
00:08:57.140 weight. And it is true that every time I've done a resting metabolic expenditure test, or anytime I've
00:09:04.460 done the more elaborate stuff, I've actually done the doubly labeled water test in the metabolic
00:09:07.960 chambers, I always seem to have a through-the-roof energy expenditure for my body weight.
00:09:14.020 So I guess for the first time that all kind of came together, which was, wow, on the one hand,
00:09:18.000 I have an advantage, perhaps, in that I have a very high energy expenditure. So relative to somebody
00:09:23.080 else who eats as much as I do, I'm going to be leaner. But the flip side of that is I'm actually
00:09:27.600 quite inefficient at utilizing energy. So again, I found that very, very interesting. One of the other
00:09:32.840 things we talked about was, hey, is there anything that a person can do besides the obvious,
00:09:37.540 which is training to boost their VO2 max? He mentioned something about beetroot. Wasn't
00:09:42.200 familiar with this, but beetroot concentrate, he said, is rich in nitrates. Body converts it into
00:09:46.860 nitric oxide. And that, of course, helps with vasodilation, opens up capillary beds. It should
00:09:51.680 be stated then, of course, that anything that impairs nitric oxide synthase, and there are many
00:09:56.180 things that do from homocysteine to insulin resistance, is going to impede it. Again, he said at the elite
00:10:01.880 level, this doesn't have much of a difference. But in amateur athletes, like the rest of us,
00:10:07.040 can be about a 5% boost. The other thing he talked about that I thought was really interesting
00:10:10.840 was, and again, this was to me just more gamesmanship than anything else. And I can't
00:10:14.580 wait to try it the next time I do a VO2 max test, which, by the way, is probably going to be this
00:10:18.340 weekend or next. He said, as you approach failure, do a few breath holds. And he said that that produces
00:10:25.320 a significant boost in VO2 max. Again, it's just a reactive overconsumption of oxygen. I don't know
00:10:30.600 if that means anything. One of the other things that I asked him about was the use of acetaminophen.
00:10:37.360 Again, there are some data that suggests that acetaminophen use can boost peak endurance
00:10:42.960 performance by 1% to 2%. I asked Olaf if Christian or Gustav used acetaminophen themselves during
00:10:50.000 Ironman, and he said they did not. And he raised a point that I thought was interesting, which is,
00:10:54.900 well, acetaminophen or Tylenol can obviously reduce the perception of pain, which has been one of the
00:10:59.800 arguments for why it boosts performance. It may impair the athlete from giving off heat from heat
00:11:05.380 dissipation. And so he just questioned whether or not that might be a worthwhile trade-off. Of course,
00:11:10.000 for me, that begs the desire to do an experiment and find out. Another area that we talked about,
00:11:14.980 which, again, isn't relevant to me and the way I train, but if any of you are listening and you are
00:11:19.260 really high-performance athletes, I think this is arguably probably the single most important takeaway
00:11:24.180 from this podcast, is what the upper limits of carbohydrate consumption are while doing cardio
00:11:30.100 activity and racing. So again, if you're a triathlete, if you're a cyclist, if you're a
00:11:35.000 runner, less applicable in running because the races are typically so short. But of course, if you're an
00:11:39.120 ultramarathon runner, that would not be the case. So everybody's kind of done this math, which is if
00:11:43.580 you're doing an Ironman or something like that, you're probably, depending on your level of fitness,
00:11:47.800 expending somewhere between 700 and 1,000 kilocalories per hour. Let's even be conservative
00:11:56.420 and say you're really, really just going easy. You'd be at 600 to 700 kcal per hour. Now, we don't
00:12:02.920 have that much stored glycogen. You've got maybe 50, 100, maybe 200 grams of glycogen if you have
00:12:11.860 really big muscles stored, which you're going to run out of pretty quickly. That's going to supply
00:12:17.420 you for maybe an hour and a half. So thereafter, you have to meet your needs from body fat and
00:12:23.640 intake of carbohydrates. And the conventional thinking has always been that you can only
00:12:27.860 consume about 60 grams of glucose per hour. And 60 grams of glucose, of course, is only about 240
00:12:33.980 kilocalories. This has always been one of my main arguments for why being fat adapted is very important
00:12:40.180 because if you're consuming that 60 of glucose and that's giving you whatever it's giving you,
00:12:44.600 you have to get the balance from fat and you're only going to do that if you're heavily fat adapted.
00:12:48.160 So you get into this cycle. Well, what we've seen unquestionably is I think the biggest,
00:12:53.220 honestly, the biggest innovation in endurance sports like the Tour de France and Ironman
00:12:57.800 over the past decade is the amount of glucose that these guys are able to consume.
00:13:02.800 He talked about numbers I had never heard before. As some of you may recall, I interviewed
00:13:07.120 Tadej Pogacar recently, the greatest cyclist on the planet. His numbers blew my mind of the type
00:13:12.600 of carbohydrate intake that he was tolerating, 150, 180 grams per hour. Olaf said that they're now
00:13:20.140 pushing triathletes at the world-class level to 240 grams per hour. Again, this is unbelievable to
00:13:26.720 me. And what that basically tells you is you can meet all of your glycolytic needs indefinitely
00:13:32.240 through that. Now, again, just as Tadej said, you have to train this system. These are athletes that are
00:13:39.800 required to now consume gels and eat carbohydrates at a 12% mixture. What does that mean? 12% mixture
00:13:48.160 means 120 grams per liter. 10% mixture is 100 grams per liter, etc. Conventional wisdom is that we can't
00:13:58.220 tolerate, meaning our gastrointestinal system cannot tolerate more than a 5% mixture. And I know for me
00:14:04.560 personally, when I used to be doing ultra distance stuff, I had a hard time going above 5% to 6%
00:14:10.020 myself. But what Olaf said and what Tadej has also said separately is you can actually train your GI
00:14:16.760 system to double that. And so how these guys are drinking two liters per hour of a 12% mixture,
00:14:23.420 which would be 240 grams, I simply can't fathom. But clearly that's what they're doing. Or they're doing
00:14:28.920 it in some combination. So they're consuming gels plus water that amounts to that mixture. But I
00:14:34.340 think when you look at the hyperbolic performance of endurance athletes today, it's very quick and
00:14:40.500 tempting to just say, ah, they must be just using drugs we haven't figured out yet. Yeah. It's also
00:14:44.620 the fact that I think another explanation and the one that I find more appealing is that they literally
00:14:50.420 figured out how to double the octane of the fuel. I mean, that's effectively what's happening.
00:14:55.080 It's like a car that went from racing at 70 octane to 140 octane. And I'm not going to bother explaining
00:15:02.540 what octane is. I'm not even sure if there's a 140, but you know what I'm getting at. So I would say
00:15:06.640 those are probably the most important things. I guess the last thing that I would take away from
00:15:12.180 this is he offered a great protocol for how to make sure you're giving it your best when you do a
00:15:19.340 VO2 max test. This has already been something that I've started implementing a little bit more with
00:15:25.000 our patients and making sure that, for example, if they do a VO2 max test, I've always asked people
00:15:30.280 to describe the protocol. And many times I'm not pleased with the protocol, but this was the kind
00:15:34.580 of, I think, really super duper protocol. You want to do this at the time of day that is a normal time
00:15:40.960 that you would be training. So you want to be well rested, et cetera. Minimize traveling the day
00:15:45.020 before. So we try to tell our patients the same thing. If you're coming into Austin for a VO2 max test,
00:15:50.740 boy, it would be really great if it was just a short flight the day before. And if it's
00:15:54.280 international, please come in more than a day before, if you want to maximize the test,
00:15:58.080 the warmup should be basically six minutes. Very, very easy. Six minutes zone two, three minutes at
00:16:06.680 threshold or FTP two to three times at a 10 to 15 second burst at about what you expect your PVO2 max is
00:16:15.680 then a relatively short rest of 10 to 15 minutes, get a drink and then get on with it. Yeah. So I would
00:16:22.700 say that those are probably the most important things, Nick, that I took away from this podcast.
00:16:26.120 So Peter, just a few follow-up questions there. Let's just start with the VO2 max training. So
00:16:33.280 in that protocol, it actually is like a decent warmup that you're having people do.
00:16:38.040 I remember when I've done VO2 max testing, I don't know if they even really had me do
00:16:42.680 any type of warmup. You just kind of went, hit the treadmill and then started going. So you're
00:16:47.640 having people go through a little bit of a workout before they get going.
00:16:52.560 Yeah. And I'll tell you this. I do most of my VO2 max testing outdoors. Now I use that VO2 master
00:16:57.360 device, which I love. I'm going to leave from my house. I'm going to ride 10 to 15 minutes to the
00:17:03.700 place where I do my hill repeat. So that's a warmup in and of itself. And by the way, getting there,
00:17:08.660 there are a couple of short little climbs where I'll do 30 seconds of relatively high power just to
00:17:13.440 get up over a little pitch. I will do two to three full runs of the hill at escalating power
00:17:21.220 before I'm truly going to hit my max. So I'll do like a four to five minute up, maybe 85% of what
00:17:29.280 my maximum power would be for that climb, come down for the same amount of rest period, go up again
00:17:35.440 at maybe 90% of what my maximum power would be, come back down, and then maybe I would go and give
00:17:41.680 it. The third one would be out there. So by the time I've done it, I've really warmed up. And so
00:17:45.120 the other day I was talking to a patient who did his VO2 max test at a facility. It was at a university
00:17:50.200 that he went to do it. It was just like a place where you can go and pay to do it. And I was kind
00:17:53.940 of surprised at what his number was. It was lower than I expected given his training. I said, tell me
00:17:59.100 about the protocol. And he's like, yeah, I just got on the treadmill and they just started cranking it.
00:18:02.340 And I was like, and how long after you started on the treadmill, did you hit VO2 max? And he's like,
00:18:06.280 I don't know, five minutes. And I was like, yeah, that's a garbage protocol. You were not warmed up and ready to do 0.98
00:18:11.500 that. You mentioned you have a VO2 max coming up. When was the last time you tested prior to this?
00:18:17.260 In the spring. And the reason is because I like doing it outdoors. I have noticed because I live
00:18:23.360 in Texas, how much of a performance hit I take in the summer. Like it's a noticeable difference in
00:18:29.780 the summer. So I'm like, yeah, I just would rather do it in the spring. Fall, winter, spring is when I
00:18:34.060 prefer to test. Let's say the month leading up to it. So the past month, have you changed your
00:18:38.860 training at all? Are you doing anything in particular for it? Not at all. This is just
00:18:43.120 a data check. It's just like, I had my blood drawn this week, had my DEXA scan a couple of weeks ago.
00:18:48.160 I'm doing a VO2 max. In general. So if you haven't changed anything, just as a reminder for people,
00:18:53.720 what is your VO2 max training look like in a typical week? Is that one day a week?
00:19:00.080 Just one day a week. Yeah. It's three days a week of zone two and one day a week of interval training.
00:19:05.700 But interval training at that specific four, five, upper limit, eight minute intervals.
00:19:13.160 And I always like when we talk VO2 max training, I think back to one of the actually first video
00:19:17.860 podcasts we ever did with Alex Hutchinson. Do you kind of want to walk people through,
00:19:21.740 I think a lot of times when you think of VO2 max training or Tabata training or like going all out,
00:19:27.960 a lot of times people kind of lose sight at how hard that actually is. Do you kind of want to walk
00:19:34.620 through if you're doing actual intervals, real VO2 max training, what that feels like?
00:19:40.700 VO2 max training hurts less than a true Tabata. I mean, a true Tabata, that's where I think people
00:19:48.060 have a hard time understanding what all out means. I mean, technically, I don't think the human body is
00:19:52.640 capable of going all out for more than 10 seconds. So even at the level of a Tabata, which is a 20 second
00:19:59.000 effort followed by a 10 second rest repeated eight times or done eight times, even a 20 second,
00:20:06.000 there's just a governor that is self-regulating how hard you go. The reverse Tabata, where you go 10
00:20:12.620 seconds all out, 20 seconds rest for eight rounds. That's about the closest thing that I think we're
00:20:18.380 capable of doing as a truly all out. You will increase your VO2 max doing that type of an exercise,
00:20:24.480 but not nearly, not nearly as much as if you're doing intervals in the three to eight minute range.
00:20:30.940 And by definition, if you're doing something for three to eight minutes, you're not going all out.
00:20:34.860 What you're trying to do is go as hard as you can for that distance and for that time. So it's a
00:20:42.640 different animal. Obviously, I think it hurts more because it's a lower level of peak pain, but it's
00:20:47.380 spread out over a longer period of time. So the area under the pain curve is greater, but it's far from
00:20:53.240 all out. And at any moment in time, the pain is not the same. Can you remind people, let's say you're
00:20:59.600 doing a four minute interval. You're not starting at four minutes, going as hard as you can, and then
00:21:05.700 trying to sustain it. Can you walk through how you think about the energy you put out spread across
00:21:11.200 four minutes? Yeah. Technically the power is constant throughout the four minutes. So I know in my mind
00:21:17.660 how many watts I want to produce and what I want my average wattage to be over the five minutes. So
00:21:24.080 let's just say I want to do five minutes at 300 watts. Of course you're outdoors, so you don't have
00:21:30.380 complete control. It's always jumping around, but I'm really watching the three second power tracing and
00:21:35.720 the average power to keep it there. Well, after the first minute, I barely know I'm on the bike.
00:21:40.360 It should be really easy after a minute. If you're dying after the first minute, you've set your target
00:21:45.820 too high. Two minutes in, you know, or two and a half minutes in when I'm halfway done, I still feel
00:21:51.280 pretty good. My heart rate is now going to be within about five beats of what its maximum is,
00:21:57.940 but I still feel pretty good. It's really at about minute three, three and a half that the pain train
00:22:03.920 starts to leave the station. And that's when it really starts to feel miserable. And that last minute
00:22:09.040 is really, really difficult. If you've done this right, when you finish this, you're really going to need
00:22:14.940 that four or five minutes of very, very easy peddling to let your heart rate come back down
00:22:20.560 to then repeat it. But again, the goal is not to have killed yourself in that five minutes such that
00:22:26.140 you can't do it again. Because what I'm trying to do is actually preserve that power across all the
00:22:31.420 intervals. Got it. Last follow-up on this is you talked about the consumption and like the increase in
00:22:38.160 performance as a result of what they're able to consume when they're performing. How much of a
00:22:43.240 difference do you think that makes? Or how can you explain it? A lot of lay people probably aren't
00:22:48.380 thinking about that consumption or their mixture. I know a lot of endurance athletes are, but
00:22:52.440 how much of a game changer do you think it is to have that increase in what they're able to put in
00:22:58.200 their body during events? Well, again, for people like me and probably most people listening to this
00:23:04.620 podcast, this is not something that should be on our radar. I don't think there's ever going to be a
00:23:08.960 day when I'm doing a 10-hour endurance event again. And therefore, I don't really need to worry about
00:23:14.100 it. If I'm exercising for two hours, that's kind of a long time. So at two hours, I'm fine with just
00:23:19.640 water. I'm living off my own glycogen and whatever. But it's very difficult now to think about people
00:23:26.260 competing at a world-class level in cycling and Ironman because what Olaf and many others have now
00:23:32.820 argued is the problem of peak endurance is effectively an energetic problem. It's basically a
00:23:39.320 question of how much chemical energy in the form of food can you convert into electrical energy
00:23:46.580 via the metabolism of food back into chemical energy in the form of ATP, back into mechanical
00:23:53.420 energy. It's just an energy transfer problem. And more energy input means more energy output. The more
00:23:59.840 logs you can put into the fire, the hotter the fire burns, the more steam it makes, the faster the
00:24:06.760 wheel turns. That's basically what it comes down to. And what we've seen over the past decade is
00:24:11.360 quite literally a more than doubling of the feedstock that goes into the furnace.
00:24:18.140 Got it. All right. Anything else on Olaf before we move on?
00:24:21.860 No.
00:24:22.500 Perfect. So next is Ralph on insulin resistance, which I think you said was one of the more
00:24:29.840 interesting interviews you've ever done, correct?
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