The Peter Attia Drive - April 22, 2019


#50 - AMA #5： calcium scores, centenarian olympics, exercise, muscle glycogen, keto, and more


Episode Stats


Length

11 minutes

Words per minute

179.06807

Word count

2,129

Sentence count

124


Summary

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

In this episode of The Drive, I talk about why we don't run ads on this podcast and why we rely entirely on listener support to sustain it. I also talk about the benefits of a subscriber-based model for supporting The Drive.

Transcript

Transcript generated with Whisper (turbo).
00:00:00.000 Hey everyone, welcome to the Peter Atiyah Drive. I'm your host, Peter Atiyah.
00:00:10.140 The drive is a result of my hunger for optimizing performance, health, longevity, critical thinking,
00:00:15.600 along with a few other obsessions along the way. I've spent the last several years working with
00:00:19.840 some of the most successful top performing individuals in the world. And this podcast
00:00:23.600 is my attempt to synthesize what I've learned along the way to help you live a higher quality,
00:00:28.360 more fulfilling life. If you enjoy this podcast, you can find more information on today's episode
00:00:33.000 and other topics at peteratiyahmd.com.
00:00:41.440 Hey everybody, welcome to this week's episode of The Drive. I'd like to take a couple of minutes to
00:00:46.160 talk about why we don't run ads on this podcast and why instead we've chosen to rely entirely on
00:00:51.660 listener support. If you're listening to this, you probably already know, but the two things I care
00:00:56.480 most about professionally are how to live longer and how to live better. I have a complete fascination
00:01:02.760 and obsession with this topic. I practice it professionally and I've seen firsthand how
00:01:07.480 access to information is basically all people need to make better decisions and improve the
00:01:12.120 quality of their lives. Curating and sharing this knowledge is not easy. And even before starting the
00:01:17.600 podcast, that became clear to me. The sheer volume of material published in this space is overwhelming.
00:01:22.840 I'm fortunate to have a great team that helps me continue learning and sharing this information
00:01:27.880 with you. To take one example, our show notes are in a league of their own. In fact, we now have a
00:01:33.840 full-time person that is dedicated to producing those and the feedback has mirrored this. So all of
00:01:39.580 this raises a natural question. How will we continue to fund the work necessary to support this? As you
00:01:45.980 probably know, the tried and true way to do this is to sell ads. But after a lot of contemplation,
00:01:51.120 that model just doesn't feel right to me for a few reasons. Now, the first and most important of
00:01:56.300 these is trust. I'm not sure how you could trust me if I'm telling you about something when you know
00:02:02.100 I'm being paid by the company that makes it to tell you about it. Another reason selling ads doesn't
00:02:07.580 feel right to me is because I just know myself. I have a really hard time advocating for something that
00:02:13.060 I'm not absolutely nuts for. So if I don't feel that way about something, I don't know how I can talk
00:02:18.780 about it enthusiastically. So instead of selling ads, I've chosen to do what a handful of others
00:02:23.680 have proved can work over time. And that is to create a subscriber support model for my audience.
00:02:30.240 This keeps my relationship with you both simple and honest. If you value what I'm doing,
00:02:36.260 you can become a member and support us at whatever level works for you. In exchange,
00:02:41.340 you'll get the benefits above and beyond what's available for free. It's that simple.
00:02:45.380 It's my goal to ensure that no matter what level you choose to support us at, you will get back
00:02:50.940 more than you give. So for example, members will receive full access to the exclusive show notes,
00:02:58.680 including other things that we plan to build upon, such as the downloadable transcripts for each
00:03:05.320 episode. These are useful beyond just the podcast, especially given the technical nature of many of
00:03:10.300 our shows. Members also get exclusive access to listen to and participate in the regular ask me
00:03:17.440 anything episodes. That means asking questions directly into the AMA portal and also getting to hear
00:03:24.320 these podcasts when they come out. Lastly, and this is something I'm really excited about. I want my
00:03:29.660 supporters to get the best deals possible on the products that I love. And as I said, we're not taking
00:03:34.600 ad dollars from anyone, but instead what I'd like to do is work with companies who make the products
00:03:39.200 that I already love and would already talk about for free and have them pass savings on to you.
00:03:45.860 Again, the podcast will remain free to all, but my hope is that many of you will find enough value in
00:03:52.880 one, the podcast itself, and two, the additional content exclusive for members to support us at a
00:04:00.040 level that makes sense for you. I want to thank you for taking a moment to listen to this. If you learn
00:04:04.800 from and find value in the content I produce, please consider supporting us directly by signing
00:04:10.300 up for a monthly subscription. Welcome to AMA number five. As always, I'm joined by Bob Kaplan,
00:04:15.580 my head of research. As a reminder, these are for subscribers only. And if you're a subscriber,
00:04:19.400 you can watch or listen to this full episode on our website. If you're listening to this on your
00:04:23.520 podcast player, you'll hear a preview here, and then you'll have to finish listening to it on our
00:04:26.820 website. Please continue to ask questions on our AMA forum as we look forward to continuing to answer
00:04:31.980 them. In this episode, we talk about calcium scores or CACs. We do kind of a deep dive into exercise,
00:04:38.520 talking about my notion of the centenarian Olympics and how you would exercise at 25,
00:04:44.120 knowing what you know now. Talk about the tenets of exercise, and I go on a little rant about Tabata.
00:04:49.580 I go into glycogen during anaerobic exercise while on keto and some of the things I learned back in my
00:04:55.280 time of nonstop keto. I also finally divulge the Atiyah curry recipe, which I think if I were only
00:05:01.980 allowed to eat one thing for the rest of my life, that's probably what it would be. And finally,
00:05:06.440 on this episode, we reveal the egg boxing belts, how they kind of make a silent appearance, but they're
00:05:12.120 unmistakable. Welcome to another AMA. So let's just dive right in. A lot of questions came in on
00:05:21.420 coronary artery, calcium, or CAC. And so just, this is a general question. What is the deal with CAC?
00:05:29.540 Some people say it's a marker. Other people say something else. So take it away.
00:05:36.280 So a coronary calcium score is a CT scan that's done dry, meaning without any contrast. So you
00:05:42.300 lay on the CT table and it's a very quick scan. And because there's no contrast, anytime you see
00:05:49.580 something that's really, really bright white in there, which is normally what color contrast would
00:05:53.440 be, you know, it's calcium. So there's a scoring system where you can actually get some anatomic
00:05:59.740 detail, not to the degree of understanding how much narrowing there is of the arterial lumen,
00:06:05.120 but you can see which arteries. So the left main artery, the circumflex artery, the left anterior
00:06:11.640 descending, the right artery, the posterior descending artery. And the amount of calcification is then scored
00:06:18.280 and ranked against a percentile. So, you know, this is one of those things that is certainly
00:06:25.500 helpful. And, you know, if there's one branch of statistics that medicine sort of innately teaches
00:06:31.660 you, it's Bayes' theorem, where you update your probability based on new information.
00:06:38.200 My problem is not with the calcium score. It's with sort of a school of thought that says,
00:06:42.940 well, a calcium score, if it's zero, means nothing matters. You know, you're sort of scot-free. And
00:06:48.500 that's, you know, unfortunately, that's just categorically untrue. And the data bear that out.
00:06:52.960 So a negative calcium score, meaning a calcium score of zero, absolutely means actuarially at the
00:07:00.820 population level, a lower risk of a coronary event. And when we say coronary event, the term MACE is what
00:07:07.160 we use to describe it, a major adverse coronary event or cardiac event. So heart attack, stroke,
00:07:12.480 or cardiac death, but it's not zero. Furthermore, and this is where it gets a little complicated,
00:07:18.480 nearly 50% of fatal MIs occur in non-calcified areas of coronary arteries. Now, those data are
00:07:27.580 also a bit misleading because many of those patients still had calcifications elsewhere.
00:07:32.260 So the way I think of calcification is it tells you how many times you've been broken into and what
00:07:39.660 kind of repair you've done. I mean, that's a gross approximation. So a biomarker tells you how bad a
00:07:45.580 neighborhood you live in. So if you do a blood test on somebody and their, you know, LP little a is high
00:07:50.720 or their LDLP is high and they have lots of inflammation and all these other things, that says
00:07:55.140 you live in a bad neighborhood. It's dangerous. There's, there's a chance there's going to be a
00:07:58.220 break-in. When you see a calcium score that's anything other than zero, well, that tells you
00:08:03.600 you've already had an advanced lesion and that lesion had to be repaired because when you, and I won't
00:08:09.360 go through Starry's seven levels of atherosclerosis because it's really complicated and it's hard to do
00:08:14.640 without pictures. We had a whiteboard last time. We needed the whiteboard this time. We can throw in the
00:08:19.600 show notes. Yeah, that's right. We can put in the show notes, which is the sort of different types of
00:08:23.100 lesions of atherosclerosis, but calcification is an incredibly late stage repair. So when you have
00:08:29.400 calcification in a coronary artery, I mean, you've had real damage and it's been repaired and that
00:08:36.380 becomes a marker of risk that basically suggests you need to be more aggressive in taking care of this
00:08:42.060 case. But when it is zero, it doesn't change the fact that you live in a bad neighborhood and it
00:08:46.880 doesn't change the fact that you can have lots of arterial damage that just hasn't shown up at the
00:08:51.940 stage of calcification. So you can have plenty of soft plaque that's still there without
00:08:56.820 calcification. That's still an enormous marker of risk. And that doesn't get picked up with
00:09:00.880 no. So what we typically do with patients is, and it depends, every case is different. And so,
00:09:06.480 you know, there are some times when I just do a calcium score on a patient and if it's zero,
00:09:10.320 I don't do anything further. There are other times when even if it is zero, I still reflex into a
00:09:16.020 coronary angiogram. So a CT angiogram, which does pull much more anatomic detail.
00:09:21.940 Including the presence of soft plaque. But even there, you still can't really see plaque that
00:09:28.340 is vulnerable. But if a patient has a coronary calcium score that is zero and their CT angiogram
00:09:34.120 looks impeccable, that's a much better sign than anything not being in that case. And of course,
00:09:40.540 it begs the question, well, would you still treat a patient in that situation? That's a hard question,
00:09:45.100 but it also depends on your timeframe. And so the younger a patient is with that finding,
00:09:50.440 the less confident you are that they are one of the lucky people that seems largely immune
00:09:55.140 from coronary artery disease. Where I find these tests most helpful is actually not in young people,
00:09:59.300 but in older people.
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