TRIGGERnometry - The Truth About Ozempic, Sugar and Big Food - Dr. Peter Attia

00:00:00.640 You mentioned, you know, the hamburger that you eat today is not the hamburger you had 50 years ago.

00:00:05.140 Why is that?

00:00:05.980 I mean, in a word, it's scale and economics.

00:00:08.700 The truth of it is, agriculture is broken.

00:00:11.940 The standard American diet that we have is nothing more than a solution to a business problem.

00:00:18.660 Crop subsidies led to basically the total destruction of soil in the United States.

00:00:25.540 And if nutrient density goes down, you have to eat more of something.

00:00:29.600 All of this is probably not the end of the world if we didn't consume it in excess.

00:00:36.460 Peter, it's great to finally have you on the show, man.

00:00:39.780 Last time we were here, you very kindly gave us a couple of copies of your book.

00:00:44.360 And I was not someone who actually paid too much attention to my health prior to that.

00:00:48.340 I was just kind of naturally thin.

00:00:49.780 And so I was like, you know, I'm really healthy.

00:00:52.400 And then on the plane back, I started reading the book and I couldn't put it down.

00:00:56.500 And by the time we landed, I'd finished the book.

00:00:58.460 And then started actually looking into a lot of the stuff that you're talking about, which is all about how to be healthy in a world in which medicine hasn't caught up to many other things that are going on.

00:01:10.380 So talk to us about that, first of all.

00:01:11.900 Like, you have this concept of medicine 2.0 and 3.0, which is really interesting.

00:01:16.440 Well, first off, thanks for having me, guys.

00:01:18.860 As you know, because we've talked about it over many meals, I mean, I'm just such a huge fan of your podcast.

00:01:23.800 I enjoy it on all topics.

00:01:26.340 So it's an honor to be here and talk about my pet topic.

00:01:29.960 So, yeah, so medicine 2.0, I think to understand it, you sort of have to understand a little bit of what medicine 1.0 was.

00:01:36.440 So this is basically an evolution of how we think about medicine.

00:01:39.800 And for most of human history, you know, dating back thousands of years, there was no scientific basis for medicine.

00:01:47.840 So we didn't, without a scientific method, you can't really practice the process of science.

00:01:53.520 And therefore, anything that was imputed about illness was really, you know, thought to be based on the gods or bad humors or things of that nature.

00:02:03.300 So when a person was ill, you didn't really know what to attribute it to, right?

00:02:07.880 So medicine 1.0 sort of evolved into medicine 2.0 in the latter part of the 19th century.

00:02:14.560 Again, it wasn't just at the advent of the scientific method, which came along 300 years earlier, but it was really other tools that enabled it.

00:02:22.220 And one of the most important was the light microscope.

00:02:23.920 So the moment we as a species could appreciate microscopic entities, bacteria namely, and also eventually come to understand that there were things like viruses, it created a whole new infrastructure in the way we thought and the way we treated disease.

00:02:39.180 And then when you add to that the advent of antimicrobial therapy and antibiotics, really medicine changed.

00:02:45.620 And it sounds like overnight, because in the grand timescale of human civilization, it was almost an overnight change.

00:02:52.960 And it produced an almost overnight, although in reality four or five generations, doubling of human lifespan.

00:02:59.160 So we went from basically living to a life expectancy of the late 30s and early 40s to now late 70s, early 80s.

00:03:07.240 And that's largely been due to kind of the amelioration of the following.

00:03:12.000 So we are much better at treating trauma.

00:03:15.160 We are much better at infant mortality and maternal mortality.

00:03:19.620 And we are much better at treating acute conditions, primarily those that involve infections.

00:03:24.560 So it's largely been those three things that have doubled human lifespan.

00:03:29.220 And so Medicine 2.0 is humming along, and it's the thing that we're swimming in, right?

00:03:35.880 That's the water of medicine today.

00:03:38.440 And again, it's very good.

00:03:39.980 We collectively wouldn't be sitting here without Medicine 2.0.

00:03:43.600 What I argue in the book is that unlike where Medicine 2.0 completely displaced Medicine 1.0,

00:03:49.940 we don't need a Medicine 3.0 to displace 2.0.

00:03:53.020 We want to preserve all the benefits of 2.0.

00:03:55.100 But what we need to do is sort of allocate part of the portfolio to this thing called Medicine 3.0,

00:04:00.280 which is slightly different.

00:04:02.300 Instead of trying to apply the hammer of treat something when it arrives,

00:04:06.700 which is the Medicine 2.0 strategy, that doesn't seem to work with chronic diseases.

00:04:11.980 And it's now chronic diseases that are killing most people in the developed world.

00:04:15.980 We instead have to prevent these things decades before they show up.

00:04:19.740 So you don't treat heart disease when a person has coronary plaque, right?

00:04:24.600 That's a process that's been going on for 50 years.

00:04:27.040 Sorry, Peter, to stop you there, because there's going to be a lot of people listening to this

00:04:30.180 who don't know what coronary plaque is.

00:04:31.980 So can you just explain it to them and then move on?

00:04:35.000 Sure.

00:04:35.600 So if somebody has a heart attack, why is that, right?

00:04:39.500 So cardiovascular disease is the leading cause of death globally.

00:04:42.500 19 million people per year die from cardiovascular disease.

00:04:46.220 Number two, by comparison, is cancer at 13 million.

00:04:49.840 So cardiovascular disease occurs when plaque accumulates in the arteries of the heart.

00:04:57.220 And the heart is very sensitive to anything that reduces its blood flow and subsequent oxygen

00:05:04.500 delivery.

00:05:06.240 And so these plaques accumulate very, very slowly on the order of decades, not years.

00:05:12.780 And we know that these plaques are accumulating in teenagers.

00:05:16.560 And we know this because when you look at cases of young men and women who die in trauma

00:05:22.200 for reasons that have no relation to heart disease, you still see on autopsy small amounts

00:05:27.960 of coronary plaque accumulating.

00:05:30.200 And so the idea that we should wait until those coronary plaques become significant enough

00:05:35.200 that either A, somebody has their first heart attack, or B, you do a study on them, like

00:05:40.320 a CT scan of the heart, where you can visibly see the coronary plaque.

00:05:43.840 And then we decide to treat them, which would kind of be part of the way that most people

00:05:49.680 would think about this, probably doesn't make sense, right?

00:05:53.440 When instead, you might want to be treating that decades before it shows up.

00:05:58.140 In other words, using that as an example, you want to treat the causal agents of the disease

00:06:03.560 and not wait for the disease to take hold.

00:06:06.120 So an example of where Medicine 2.0 does this very well is with smoking, right?

00:06:10.540 So with smoking, there's nobody out there saying, we should get people to stop smoking once they

00:06:18.660 start to develop nodules in their lung that look suspicious for cancer.

00:06:22.900 We don't say that.

00:06:24.160 Why?

00:06:24.660 Because we know that smoking is causally related to lung cancer.

00:06:28.460 And when you know that, you tell people to never smoke.

00:06:32.920 And the minute they start smoking, you get them to stop regardless of risk.

00:06:36.940 And meaning regardless of age or any other risk factor.

00:06:40.540 Similarly, we know what the causal drivers are of cardiovascular disease, right?

00:06:44.860 So it's, the technical term is hyperbeta lipoproteinemia.

00:06:48.340 That's just a very fancy way of saying the types of cholesterol-carrying molecules that

00:06:53.580 have a certain thing on them called ApoB.

00:06:55.680 So that's the LDL, the VLDL, the IDL, LP little a.

00:07:00.060 All of those little particles are causally related.

00:07:02.960 High blood pressure is causally related.

00:07:05.140 Insulin resistance is causally related.

00:07:07.080 So what we want to be able to do is treat those things the second they emerge.

00:07:11.020 Even if a person is young, otherwise healthy, or otherwise low risk.

00:07:16.180 Another very important tenet of Medicine 3.0 is not just the early and aggressive primordial

00:07:22.780 prevention, but it's also this emphasis on health span as being equal to lifespan.

00:07:27.880 So lifespan, I think, is a pretty obvious concept.

00:07:30.820 It's how long you live, and it's quite binary, which makes it easier to understand you're

00:07:36.120 alive or you're dead.

00:07:37.160 Health span is a little more subjective, and what one person deems exceptional health span

00:07:43.640 might not be that of another.

00:07:44.660 But regardless, I think people intuitively understand what quality of life means.

00:07:49.200 And it has a sort of physical, cognitive, emotional component.

00:07:52.460 And Medicine 3.0 would treat the optimization of that at the same level.

00:07:57.700 It's equally important to how long you live.

00:08:01.000 And that's important because what gets measured gets managed, right?

00:08:04.400 And so Medicine 2.0 really optimizes around lifespan, and therefore that's the metric that

00:08:10.300 we track.

00:08:11.500 Well, that was really the thing that shook me kind of awake when I was reading the book,

00:08:17.140 because you have this, I think it's a graph and also an explanation to basically show,

00:08:22.460 I mean, this may be overstating it slightly, but the way we currently manage health is essentially

00:08:26.380 we live, then we get sick, and then medicine comes in and extends as much as possible the

00:08:33.940 period of our life when we are sick so that we can live longer.

00:08:38.200 But you're living longer while really actually having some real issues, right?

00:08:42.780 And what you were talking about in the book very powerfully is how do you extend the period

00:08:47.360 of life when you're not sick so that you kind of have a very short period of the end of your

00:08:51.800 life when you are maybe dealing with issues, and then you die.

00:08:54.960 So you're kind of extending your actual high quality life.

00:08:59.500 And that seems to me like a pretty good thing to be doing.

00:09:02.940 I think that's honestly what anybody who puts a lot of thought into it will come to the conclusion.

00:09:09.420 And I say that because I spend time with lots of people where I'm asking them to really make

00:09:16.480 trade-offs and thought around that, right?

00:09:18.620 So I'm sort of saying, like, what do you want the last decade of your life to look like?

00:09:22.760 Like, really put some thought into this.

00:09:24.140 Like, this is an exercise that we do.

00:09:25.720 It's called the marginal decade exercise because we refer to that last decade of life as the

00:09:29.620 marginal decade.

00:09:31.180 And what I can tell you is I have yet to meet an individual.

00:09:34.640 Now, maybe my sample size is, you know, only, you know, hundreds instead of millions.

00:09:38.040 But I have yet to meet a person who, when contemplating their marginal decade, i.e., the last decade

00:09:45.220 of their life, something all of us will have as sure as God made little green apples, everybody

00:09:51.240 is focused far more on what they will be able to do in that decade than how old they will

00:09:57.220 be.

00:09:57.820 Now, obviously, nobody would view a marginal decade from the ages of 51 to 61 as ideal.

00:10:03.880 In other words, anybody would argue that, hey, to die at 61 would be premature and awful.

00:10:08.320 We don't want that.

00:10:09.280 So we have to take the steps to address lifespan, which means delaying the onset of chronic disease.

00:10:15.080 But I don't see anybody saying that, you know, 85 to 95 at very good health is demonstrably

00:10:25.100 worse than 100 to 110 at, you know, marginal health.

00:10:31.060 Even though you live 15 years longer, something to that effect.

00:10:35.080 So I think quality of life is actually what most people really focus on when you force

00:10:41.600 them to kind of go through the exercise of what will it tangibly look like in the end

00:10:46.940 of your life?

00:10:47.520 Do you want to be able to sit on the floor?

00:10:50.660 Do you want to be able to stand up?

00:10:52.320 How much do you want to be able to ambulate?

00:10:54.640 What does travel mean to you?

00:10:56.500 What does living alone mean?

00:10:57.940 And by living alone, I don't mean necessarily without others, but living without assistance.

00:11:01.860 Do you want to be able to live with your spouse?

00:11:04.540 Or if you are living alone, do you want to be able to care for yourself?

00:11:08.200 These are things that when people are asked to stop and reflect on them become far more

00:11:13.240 important than the how many years am I going to be?

00:11:16.180 It's a really profound point.

00:11:18.100 And one of the things that I found very interesting in your book, Peter, is when you were talking

00:11:22.520 about type 2 diabetes and how we're not actually talking about what a serious condition this

00:11:30.200 is.

00:11:30.860 And then I started looking at the stats about obesity and the proportion of people that are

00:11:38.220 overweight in this country.

00:11:39.580 Something like 74% of Americans are overweight.

00:11:42.660 I think it's something like 40% of Americans are obese.

00:11:46.060 around 10% are severely obese.

00:11:49.740 I mean, that's terrifying.

00:11:53.560 Yeah.

00:11:54.240 I mean, I think there's so many different ways to look at it.

00:11:57.860 And obviously, we need to caveat all of that by saying that there is this now new class of

00:12:03.840 drugs that more than any other drugs in the history of as long as we've been dealing with

00:12:10.560 this problem appear to be more efficacious and with fewer side effects than anything we've

00:12:17.000 seen.

00:12:17.540 So if we bracket that for a moment and say, let's come back to it, the obvious question

00:12:22.260 is, why is this epidemic happening?

00:12:25.440 And what is the implication of it from the health of the population and economically?

00:12:31.440 And what would one need to do to address it?

00:12:33.960 So we could talk about any of those that you like.

00:12:36.880 Yeah.

00:12:36.960 I think what's causing it would be a good start.

00:12:41.440 Yeah.

00:12:41.580 Let's do what's causing it, actually.

00:12:43.320 And if you could tell the story, because I found it incredibly powerful about the story

00:12:47.840 about when you were working as a surgeon.

00:12:50.300 I think it's the technical term as a surgeon's assistant.

00:12:52.780 And you were talking and you were interacting with the patient just before they went to have

00:12:59.460 a surgery and they told you they weren't an alcoholic.

00:13:02.320 Yeah.

00:13:02.620 So I was in my, and I go, we have a different system here than probably some of the, the

00:13:06.620 nomenclature in the UK.

00:13:07.940 So I was an intern at that point in time.

00:13:10.640 So I was, it was the first year of my surgical residencies.

00:13:13.640 I mean, it's the first year I was an actual doctor.

00:13:15.420 So you'd finished medical school, you've chosen your specialty.

00:13:18.340 And yes, for that, in that particular case, I was doing what was called pre-opping.

00:13:22.900 So getting a patient ready for surgery.

00:13:24.620 This was a gentleman who needed part of his colon removed for, because he had colon cancer.

00:13:31.340 And so there's a, there's just a checklist of questions you ask these patients, any patient

00:13:37.080 before they undergo surgery.

00:13:38.520 And one of the questions is about how much alcohol they drink.

00:13:41.760 And the reason for that is not to be judgmental.

00:13:43.980 It's because it really matters in terms of both the anesthesia they receive and also how

00:13:49.800 you manage potential withdrawal from alcohol following surgery when they can't actually eat

00:13:55.480 or drink anything by mouth for a few days.

00:13:57.160 So in a manner of normal discussion, this gentleman mentioned that he barely drank alcohol at all,

00:14:02.820 thought nothing of it.

00:14:04.080 And the next day when we are operating on him, and of course, because I was only the intern,

00:14:08.880 I'm not doing any actual operating.

00:14:10.740 I'm retracting.

00:14:11.840 So my job is to hold him open while the chief resident and the attending surgeon are operating.

00:14:17.040 And sure enough, his liver was malted with fat.

00:14:20.980 Now that's something you only saw historically in people who were severe drinkers.

00:14:27.160 At the time, it was very poor, this is 25, yeah, almost 25 years ago, it was very poorly

00:14:34.640 acknowledged that there was a condition called non-alcoholic fatty liver disease, right?

00:14:40.140 Where you had the same appearing liver, but it wasn't occurring because of excess alcohol.

00:14:45.880 It was excess calories that were being shunted into that very unfavorable storage location.

00:14:54.380 Now today we recognize this as an epidemic actually.

00:14:57.520 And today this is the leading indication for liver transplantation in the United States.

00:15:03.300 And, you know, that's kind of a remarkable statistic when you stop to think about it,

00:15:08.420 that there are people who are literally receiving liver transplants today because their livers have

00:15:13.540 become so cirrhotic due to the scarring and inflammation associated with excess accumulation of fat.

00:15:19.000 And again, that's both from alcohol, but also a significant portion of that is not from alcohol.

00:15:25.160 And when we say not from alcohol, what do we mean?

00:15:29.380 Well, the best of our belief system is this is really caloric excess.

00:15:33.420 So this is people who are not consuming alcohol.

00:15:36.400 And if they are, they're consuming it minimally.

00:15:38.280 But this accumulation of fat in the liver along with its concomitant metabolic derangement is

00:15:43.700 the result of excess calories being taken on relative to the level of exertion of an individual.

00:15:49.220 And is that why Americans and Westerners more broadly, because it's a big problem in the

00:15:52.780 UK as well, are so overweight?

00:15:55.260 Is it that we just eat more than we burn off?

00:15:58.180 Or is there something else going on in terms of the food system and all the rest of it?

00:16:02.240 Well, I think it's all connected.

00:16:03.480 So you have to think about it through the lens of like, what's the proximate physiologic

00:16:08.420 explanation of what's happening?

00:16:09.900 And then you can peel back the layers of, well, why is that happening?

00:16:13.380 And why is that happening?

00:16:14.460 So at the simplest level of physics, it's clearly a caloric imbalance.

00:16:19.500 Now, that's not the most helpful explanation, right?

00:16:22.300 That's sort of like saying, we're sitting in a room with 20 people.

00:16:27.520 Why are there 20 people?

00:16:28.980 Well, the physics answer is 20 more people entered this room than left the room.

00:16:36.080 Thank you.

00:16:36.760 That's very helpful.

00:16:37.920 Why?

00:16:38.460 Is there free food being given out?

00:16:40.780 Is there an interesting person in the room that they're all coming to listen to?

00:16:44.400 That's the sort of the real why that we want to get at.

00:16:47.260 So the real why as to why are people consuming more calories than they expend today relative to

00:16:55.240 any time in the past has to do with, I believe, so many factors.

00:16:59.960 And unfortunately, I think it's very tempting.

00:17:02.300 And I've done this myself, so I can take responsibility for this in some way.

00:17:06.400 It's very tempting to isolate one factor and say, it's because there is more processed food.

00:17:11.200 It's because we eat too much sugar.

00:17:13.060 It's because of social media that keeps us glued to our phones instead of being active.

00:17:17.800 It's because we are not sleeping as well.

00:17:19.920 And the truth of it is, it's a bit of everything.

00:17:23.280 There's no doubt that food is today more hyperpalatable and more calorically dense than at any time

00:17:29.980 in the past.

00:17:30.540 This is an undeniable fact over the past two decades.

00:17:33.740 It is also absolutely clear that people are, on average, less active today than they were

00:17:41.460 50 years ago.

00:17:42.840 It is also a fact today that people generally consume lower quality food.

00:17:51.320 Even, you know, the same type of thing that they might have consumed, like whether it was a hamburger

00:17:55.100 that you ate 50 years ago or a hamburger today, it's not just that the portion size is larger today.

00:17:59.980 It's that the actual quality of the food is lower.

00:18:02.660 Now, we don't necessarily know what the impact of each of these things is individually,

00:18:06.680 but it's very hard to deny that something in the way we eat is probably playing the most

00:18:13.100 dominant role.

00:18:13.940 Can I just ask this question?

00:18:15.220 Because when you were telling that story about the patient's incredibly fatty liver, you

00:18:21.860 mentioned that the guy was drinking a lot of fizzy drinks, soda.

00:18:26.580 And it made me think, number one, that's a huge problem.

00:18:29.060 But number two, it's something that I noticed here, and Constantine's mentioned it as well.

00:18:33.000 Sugar seems to be in everything here.

00:18:34.540 Yeah, like even coming over from the UK where people are hardly all slim and healthy, it's

00:18:40.480 like you get a coffee, it feels like it's got way more sugar in it than the exact...

00:18:46.160 If you go to a Starbucks, basically what I'm saying, and get a latte, that tastes way sweeter

00:18:51.860 than a latte in the UK.

00:18:53.240 Yeah.

00:18:53.700 Well, that's interesting because in theory, the latte shouldn't be much different.

00:18:57.380 If it's a true latte, it's literally like, are you putting milk in it or half and half

00:19:01.900 cream or whatever?

00:19:02.700 But no doubt, when you go to Starbucks, just to pick on Starbucks for the moment, it is

00:19:09.280 unbelievable the amount of calories and sugar that are flowing out of their Frappuccinos

00:19:14.880 and all of their drinks I can't even name.

00:19:17.540 And I do find that remarkably interesting.

00:19:19.760 I also think there's probably...

00:19:22.640 I say this probably, like not definitively, there's probably something to be said for drinking

00:19:30.420 calories in excess, being even a little more damning than eating calories in excess.

00:19:36.280 And I think there's decent evidence for that when it comes to sugar.

00:19:39.320 In other words, if a person is going to eat 50 grams of sugar versus drink 50 grams of sugar,

00:19:46.440 sugar, I think there's, in the animals, very compelling evidence that the latter is more

00:19:52.200 problematic.

00:19:53.340 The reason for it gets into a bit of technical biochemistry, but sugar is half fructose and

00:19:58.480 half glucose.

00:19:59.800 Fructose is what gives sugar its sweetness.

00:20:02.400 It's also a molecule that has a very unique metabolism.

00:20:05.480 Both of them are metabolized quite readily by cells, but the speed at which fructose is

00:20:12.040 metabolized is much higher.

00:20:14.080 And in the process of metabolizing fructose, cells have to use the currency of energy called

00:20:20.480 ATP.

00:20:21.620 So the rate of ATP depletion in cells within the gut and ultimately the liver as they metabolize

00:20:29.500 fructose requires that more energy is put into the system.

00:20:33.920 What does that mean in English?

00:20:34.860 It means that if you're drinking a lot of sugar, even though you're getting energy and you

00:20:40.360 should be satiated, it can actually have the reverse effect, which is, I need more energy.

00:20:45.160 It signals to the brain, I need more energy because there's a depletion of ATP required

00:20:49.440 to increase the speed of metabolism of it relative to glucose, right?

00:20:53.400 So this would be the difference between eating 100 calories that is half fructose, half glucose

00:20:58.260 versus eating 100 calories of glucose.

00:20:59.920 Yeah, that makes sense.

00:21:01.020 And you were talking about the decline in the quality of food.

00:21:03.640 This has been a big part, you know, by the time this video has gone out, the election

00:21:06.640 has already happened and America is over, whichever side wins.

00:21:10.140 Right.

00:21:10.320 Just so people know, we're having this discussion not knowing who's going to win the election.

00:21:14.220 Right.

00:21:14.540 Right.

00:21:14.760 Right.

00:21:15.300 But it has been made into a conversation, which I think is a good thing, that the quality

00:21:20.460 of food in America has declined over time.

00:21:23.500 And you mentioned, you know, the hamburger that you eat today is not the hamburger you

00:21:26.580 had 50 years ago.

00:21:27.720 Why is that?

00:21:29.880 I mean, in a word, it's scale and economics, right?

00:21:32.500 So we have to understand.

00:21:34.380 And I, you know, I think it's very tempting to just demonize big food.

00:21:39.140 And to be clear, I don't have a dog in this fight.

00:21:42.040 Like, I don't, I don't know anybody that works for big food.

00:21:44.840 I have no, you know, I don't own Monsanto stock.

00:21:48.000 Like, I truly think about this from purely a scientific and policy perspective.

00:21:52.940 But what I don't think people understand is the complexity that has been involved in the

00:21:59.100 agricultural revolution and what it takes to feed billions of people.

00:22:04.800 So the way I think about it is there's a problem statement, right?

00:22:08.380 What the problem statement is, so we could go back in time a hundred years and I'm going

00:22:12.380 to anoint you to the food czars of the universe. 0.99

00:22:15.440 Well, we're already fucked then. 0.98

00:22:19.260 I say to you, listen, guys, here's the problem you have to solve. 0.96

00:22:21.780 I want you to figure out a way to feed eight at the time, whatever it was, you know, four

00:22:25.780 billion people or whatever the number would have been.

00:22:27.300 It would have been less than that.

00:22:28.140 But I want you to feed it, figure out a few billions of people.

00:22:30.860 But here's the thing.

00:22:31.700 So one, you have to do that scale.

00:22:35.080 It's never been done before, right?

00:22:36.720 It used to be you had farmers that would sort of farm locally and they would sort of feed

00:22:42.360 a certain area and that would be the end of it, right?

00:22:44.200 So you have to be able to, if you build, feed a lot of people, you have to be able to transport

00:22:49.280 food and keep it from spoiling when you do.

00:22:53.440 We have to make it taste good.

00:22:55.480 We have to make it really cheap.

00:22:57.640 Go.

00:22:59.440 It's hard to imagine that people would come up with a very different system from the

00:23:04.740 one we have today.

00:23:05.720 So what I've referred to, and I'm sure I took this term from somebody else because there's

00:23:10.680 no way I was the person that came up with this, but what I've referred to as the default

00:23:14.960 food environment.

00:23:16.760 The standard American diet that we have is nothing more than a solution to a business

00:23:22.900 problem.

00:23:24.120 Now, a lot of times the solution to a business problem ends up having collateral damage.

00:23:29.980 So if you were a tobacco farmer and I said to you, what are you going to do with all this

00:23:34.820 crop you have?

00:23:36.640 And you came up with this idea.

00:23:37.820 Well, what if we roll these things up and give them to people and let them light it and

00:23:40.900 smoke it?

00:23:41.380 I mean, it's got, it seems to produce great qualities.

00:23:44.260 Have you noticed when people smoke that thing that I have on my field, they don't eat as

00:23:48.240 much, they lose weight, their mental alertness goes up and they feel better.

00:23:51.540 That's great.

00:23:52.600 So you had a business problem.

00:23:54.040 You had to get rid of that crop. 0.99

00:23:55.180 You got rid of that crop.

00:23:56.060 You made this thing.

00:23:56.800 Well, it turned out there was a nasty side effect of that that didn't show up for 20 years,

00:24:01.140 which is sort of killing people as well.

00:24:03.800 Does that mean that people set out to do that, to kill people?

00:24:06.300 Of course not.

00:24:06.800 You never want to kill your customer.

00:24:08.440 It doesn't justify anything in tobacco.

00:24:10.520 It just makes the point that people apply morality to these things when in reality, what's really

00:24:16.080 happening is these are just people trying to solve a business problem and there are unintended

00:24:19.900 consequences.

00:24:20.620 There are nonlinearities everywhere.

00:24:22.900 So the truth of it is agriculture is broken.

00:24:28.000 I think there's ample evidence to suggest, and this really goes back 100 years, right?

00:24:34.120 So if you go back to the Dust Bowl, which was 90 years ago in the middle of this country,

00:24:38.740 was really when agriculture took a turn for the worse.

00:24:41.980 So call it the 1920s into the 1930s when crop subsidies led to basically the total destruction

00:24:50.720 of soil in the United States, right?

00:24:52.900 So instead of saying, hey, we'll grow wheat this year, we'll grow soy the next year, we'll

00:24:59.720 grow a different crop the next year and rotate these crops and let the soil actually dictate

00:25:05.900 what we grow.

00:25:06.980 It turned into we're going to add more nitrogen in the form of fertilizer.

00:25:11.060 We're going to drive crop yields as much as possible.

00:25:13.500 And then, of course, you had a subsidy that came in that enabled that flywheel.

00:25:17.260 And then what happened is we've kind of eroded soil to the point where we're now completely

00:25:21.000 dependent on not just genetically modified crops, which people hear that and they get

00:25:27.880 all phosphorylated.

00:25:29.140 What that really means is crops that are now dependent on pesticides.

00:25:34.520 And we run these monocrops and we just do all of these things that produce basically

00:25:40.460 suboptimal plants that are grown in suboptimal soil that feed animals that become suboptimal

00:25:46.080 in their quality.

00:25:47.500 And again, all of this is probably not the end of the world if we didn't consume it in

00:25:52.540 excess.

00:25:53.020 So I think it just becomes like another thing that gets layered on the problem is, well,

00:25:58.200 on top of that, and some have argued, by the way, that that's another factor driving

00:26:02.040 our excess consumption, which is we have sort of a governor in us that is selecting for nutrient

00:26:07.140 quality.

00:26:08.260 And if nutrient density goes down, you have to eat more of something, right?

00:26:12.820 Like use an example.

00:26:13.980 Like if you have sort of a central mechanism for seeking out how much micronutrient you

00:26:20.560 want and you're used to getting it in a certain amount of rice and a certain amount of wheat

00:26:25.620 and a certain amount of meat, but now the actual density of those things is 30% less,

00:26:32.080 would you eat 30% more to compensate without realizing it?

00:26:35.020 So this is one of the theories of overconsumption.

00:26:38.560 Again, I don't think any one theory is entirely correct, but I suspect many theories play a

00:26:43.620 role in this.

00:26:44.580 And so we now have this population that is a lot of significant percentage or obese, morbidly

00:26:51.920 obese, almost three quarters are overweight.

00:26:54.940 That's a ticking time bomb, isn't it, Peter, for a country?

00:26:59.000 It certainly seems like it.

00:27:00.760 And then the question becomes what part of the system breaks first?

00:27:05.440 So we could talk about different parts of the system.

00:27:08.000 So let's talk about one that doesn't get that much attention, but which is sort of preparedness

00:27:12.660 for war.

00:27:13.580 So we're currently in the last, I would say, 10 to 15 years for the first time in U.S.

00:27:18.440 history when most people who show up at a recruiting station are failing a physical.

00:27:23.200 They aren't actually physically capable to meet the standards of the U.S. military.

00:27:27.340 So what is the implication of that?

00:27:29.620 Well, again, maybe the implication of that is, and maybe the implication of that is irrelevant,

00:27:34.820 right?

00:27:34.940 It might be that we're never going to fight wars again that require hundreds of thousands

00:27:38.040 of soldiers.

00:27:39.000 But what we can say with some confidence today is if we had to, we would have a problem.

00:27:45.380 Another obvious, I think more obvious implication is the economic one.

00:27:49.800 So as you guys probably know, the U.S. spends more on health care than any other country

00:27:53.620 in the world, both in absolute terms and relative terms.

00:27:55.820 In relative terms, we're spending about 18% of our GDP in health.

00:28:00.100 And that's problematic in many levels, but perhaps the most problematic aspect of that

00:28:05.700 is that the rate of health care expenditure as a function of GDP is outpacing inflation

00:28:11.440 by 3-4%, and it's been doing that without abating.

00:28:17.660 In other words, there was a day when health care spending as a function of GDP was 5%, it's

00:28:22.200 now 18%, and that it's growing because health care spending is growing faster than GDP.

00:28:28.480 Now, I've spent a lot of time on this problem, so this might be the problem I spend the most

00:28:33.280 time thinking about.

00:28:34.500 And what's driving that cost is many things, but a piece of what's driving it is our health.

00:28:39.700 It's not the only thing.

00:28:40.960 To be clear, anybody who says you are going to solve health care economics by getting everybody

00:28:46.740 healthy is wrong.

00:28:47.620 Well, aging is a massive factor, isn't it?

00:28:49.940 No, I mean, believe it or not, the biggest thing that's driving the U.S. health care

00:28:54.460 spending is the consumerism mindset of an American.

00:28:57.960 Okay.

00:28:58.380 Yeah.

00:28:58.700 So technically, the single biggest driver, because U.S. health care spending is one, well,

00:29:05.580 85% of it is divided as one-third drugs, one-third facilities, and one-third personnel.

00:29:13.500 And then 15% is administrative cost that's associated with a multi-payer system.

00:29:20.080 So which of those three buckets are being driven?

00:29:23.780 Because this administrative piece is not being driven by how sick people are.

00:29:27.300 That's simply the infrastructure of our system.

00:29:29.740 Technically, the cost of personnel is really more a function of the U.S. economy and salaries

00:29:35.940 here.

00:29:36.240 So it really comes down to facilities and medications.

00:29:39.760 And so it's really the medication bucket that is pushing hard, that you could reduce the most

00:29:45.220 by fixing the health of the population.

00:29:49.200 But again, every dollar matters when you're at 18% and trying to avoid being 19% and 20%,

00:29:56.040 which we probably will at some point if we don't fix this problem.

00:29:59.040 Um, and then I think there's sort of just the personal toll it takes, which is, you know,

00:30:04.900 it's harder to put a dollar amount on that, but there's a ton of stigma associated with

00:30:08.840 being overweight.

00:30:09.660 I don't think there's anybody out there who's walking around who's overweight, who's oblivious

00:30:13.340 to the fact, or who wants to be in that situation.

00:30:15.560 And I think many of these people are quite frustrated.

00:30:17.620 And I think it's, look, I think it's very easy to kind of demonize people who are unhealthy

00:30:20.940 and say, oh, you know, why don't you just buck her up and eat less and exercise more? 0.99

00:30:24.720 But, but I think that's, I think that's, I don't, I don't favor that approach.

00:30:28.160 And I think that, um, I think we need to have more empathy for people. 0.99

00:30:31.520 Like I think, sure, there's always the edge case of the person who just truly says, fuck 1.00

00:30:35.440 it. 1.00

00:30:36.140 Like, I just want to eat Big Macs all day and I don't care.

00:30:39.420 But I think the truth of it is for many people who are in that situation where they're, you

00:30:44.800 know, they have type two diabetes, they're overweight.

00:30:46.960 Um, I think they go through bouts and spurts of really trying and not necessarily achieving

00:30:51.720 the success they want.

00:30:52.640 We also have to sort of bake in this idea that people, I think have different amounts

00:30:56.680 of willpower and I don't know that you can take much credit for it.

00:30:59.220 So like, I tend to have very high willpower.

00:31:02.720 Um, did I do anything to hone that?

00:31:06.020 Like, isn't that kind of just like why I have brown eyes too?

00:31:09.080 Like I'm the height that I am.

00:31:11.080 I, all of the characteristics about me are largely innate and I view kind of willpower

00:31:16.080 as one of those.

00:31:17.060 Do you not think it's, I'm sure there's an element of it that's genetic.

00:31:19.860 Do you not think it's also a muscle that you train?

00:31:23.160 Like you train yourself.

00:31:24.740 But why do I train it?

00:31:26.720 You, huh?

00:31:28.420 Well, I, I.

00:31:29.160 What gives me the desire to, I agree that you practice this stuff.

00:31:32.640 Yeah.

00:31:32.920 And I put it into practice in many things I do, but I, I, this is one of those areas

00:31:37.020 where I really debate free will.

00:31:38.700 Like I'm, I mean, yeah, yes, yes, yes, I, I have, I have, I could spend hours talking

00:31:45.140 about it and demonstrating my ignorance.

00:31:47.400 Um, but, but when I examine things in myself, I tend to appreciate that I can't take credit

00:31:55.640 for much.

00:31:56.860 Luck has sort of given me, you know, maybe genes that are less susceptible, a stronger desire

00:32:04.260 to do a certain thing.

00:32:05.380 Anyway, all of this is a long winded way of saying, I think there's an enormous personal

00:32:08.480 toll of these things.

00:32:10.860 Um, I think there's, you know, a lot of denigration of, of self-worth and things of that nature.

00:32:15.580 And, and I think, look, you see this, you see this bubbling to the surface in the discussion

00:32:21.240 around GLP one agonists and their derivative drugs, right?

00:32:24.680 Which is the morality associated with using them, right?

00:32:28.800 Is it?

00:32:29.180 Those are the weight loss drugs.

00:32:30.540 That's correct.

00:32:31.080 These are drugs like, um, I don't know if they have the same names in the UK.

00:32:34.460 Yeah.

00:32:34.760 Ozempic, Monjaro.

00:32:36.560 Um, there are newer versions of these drugs that are not even yet approved that look even

00:32:41.660 more potent, right?

00:32:43.080 So, so semaglutide, which is the drug that, um, is Ozempic or Wegovi is actually the third

00:32:49.300 generation of those, of that drug.

00:32:51.600 Monjaro or Trisepatide was the fourth.

00:32:53.900 And then the next one coming out is called Retitrutide looks even better than the fourth

00:32:59.320 one, which is better than the third one, which was a log form better than the second

00:33:03.340 one.

00:33:03.760 Point is these drugs aren't going anywhere in the pipeline of these, there's 20 of these

00:33:07.560 things in the pipeline.

00:33:08.980 Um, but I think as a society, there's a lot to wrestle with because the cost of these drugs

00:33:14.000 is significant.

00:33:14.880 But I also think deep down, a lot of people think, is it, you know, you know, there's a

00:33:22.300 judgment that comes with from some, I think when it comes to their use case, of course,

00:33:26.460 yeah.

00:33:26.820 Sorry.

00:33:27.600 Finish your point.

00:33:28.460 I was just going to say that there's the economic consideration of them as well, which

00:33:31.480 everybody brings up.

00:33:32.840 Pizza.

00:33:33.220 How much of this is because I've noticed something.

00:33:36.820 So I can't drink alcohol because I just can't, I can't control myself when I'm on my alcohol.

00:33:41.580 And if I have one that will lead to many more.

00:33:44.800 I know that that's why I don't drink.

00:33:47.360 How much of this is addiction?

00:33:49.340 Because I've noticed as somebody who has a personality which is obsessive and can, if

00:33:54.440 unchecked, can lead to addiction.

00:33:56.400 I've noticed that when I eat things here, I get a little kick that I don't get back at

00:34:02.960 home.

00:34:04.020 And in particular, when you look at fast food, when you look at sugar, how much of this

00:34:08.880 accompanies putting things in their products, which they know will mean people will get

00:34:16.000 addicted to them and will come back again and again and again.

00:34:20.360 And again, I don't think it's a moral thing.

00:34:22.260 I think it's them just trying to boost profits.

00:34:24.580 Yep.

00:34:25.400 So a couple of things.

00:34:26.640 I think that I try to not use the word addiction because it has such technical meanings and I

00:34:32.300 don't want to get into the nuances of what constitutes a true addiction because there's

00:34:38.000 a very clear clinical definition, but the point is what's important, not the terminology.

00:34:44.020 So if we bracket that the word addiction may or may not apply to food for the average person,

00:34:49.960 your point is very well taken.

00:34:52.940 And I would argue that any American who has spent any time in Europe, and I love being in

00:35:00.040 Europe, will explain exactly what you've just said, which is we have the reverse experience,

00:35:05.460 right? When we go to Europe, whether we're in Italy, it doesn't matter. You could be in

00:35:09.560 the food central of Europe. You just don't tend to overeat the same way that you can in

00:35:14.740 America. And I have spent untold hours asking people, why do you think that is? What is it

00:35:23.780 in the food in Europe that seems to be different? I have never been able to find empirical evidence

00:35:28.780 to support my assertion. It's all anecdotal, but you are yet one more person to kind of ring that

00:35:35.000 anecdote true. I think there's a lot of things, right? I do agree that in Europe, the portion sizes

00:35:40.320 are so much smaller. And I think that there is, this has been an observed phenomenon that's been

00:35:45.460 done in studies. When you give a person a portion size, they will often eat past their limits. So there

00:35:51.560 was the experiments done many years ago where they gave people these drinks, right? So it was kind of

00:35:56.600 like a milkshake sort of thing. And they had one group drinking one drink and another group drinking

00:36:01.920 another, but the one group was drinking it where it was being refilled at a level that allowed it

00:36:07.900 to constantly stay higher than it would have been if they were just drinking it. And of course,

00:36:11.780 the question is, are people stopping when they're full or are they stopping when they finish? And of

00:36:17.580 course, these people were drinking more than the other people, meaning that the people who had a

00:36:21.440 refilling drink. So that would suggest that if you put more food on a person's plate,

00:36:26.020 they're going to eat more. So portion sizes matter. Most people have talked a lot about the

00:36:30.780 differences in wheat quality between Europe and the UK, pardon me, between Europe and between

00:36:35.600 North America. And obviously a big difference here is we use glyphosate on our wheat. In Europe,

00:36:40.920 it is not used. And so it's really not to me about the GMO distinction, but it is clear that there

00:36:46.580 might be a difference in the use of glyphosate. For example, people talk about how they just

00:36:50.940 don't feel as bloated when they eat things there. You've already alluded to the fact that less sugar

00:36:56.020 tends to be used, but also it's like, think of how smaller the cans and bottles are and stuff like

00:37:01.120 that. Right. So. Oh yeah, man. We went for a meal with somebody the other day and you just go to the

00:37:07.120 fridge and there's a liter bottle of Coke, a liter. And that's like, that's the minimum size you can get.

00:37:14.920 Yeah. That's fucking crazy. Yeah. So I just, I think, I think there are just so many differences 0.99

00:37:20.840 and, um, yeah, part of it is just, it's our culture here. It's everything is bigger. Everything is

00:37:29.100 better. I mean, but it's everything, right? It's like, it's, it's, our cities are bigger. They're

00:37:33.540 more spread out. Uh, our lane, I think, look at the difference in the, I'm sure you've thought of this

00:37:38.640 if you've driven here, when you drive in Europe versus when you drive in the United States, like when you

00:37:44.020 drive in the United States, you can shut your eyes half the time. The lanes are so big. When you are

00:37:48.840 driving in Europe, you have to be switched on. There is no futzing around. There's no drifting in

00:37:54.040 and out of lanes. Like everything is compact. So I just think there's a lot of this going on. Um, but

00:38:02.060 to your question, I agree completely that food science is all about engineering a product that

00:38:10.820 tastes as good as possible and gets you to buy as much as possible. And moving on to type two diabetes.

00:38:19.380 Let me just stick with this quickly on. Do you think you, it's very clear from the way you're

00:38:27.340 talking about it, Peter, the, the, the, you know, we all, I think would agree that capitalism is

00:38:32.960 a great system, but it comes with externalities. It comes with trade-offs. And I guess the question

00:38:40.580 is, do you think this can be solved by the market? Because like when we're in LA, you can get very

00:38:47.660 good food in LA. It's very expensive, but if you want to eat very clean, you can eat very clean. It is

00:38:53.120 available. Do you think this can be solved simply by the fact that, look, there's very cheap food and

00:38:59.620 if, and it's filling and whatever. And if that's what you want, you can have that. Or if you choose

00:39:05.120 to allocate a different portion of your family budget to food, because you care about health,

00:39:10.760 there's a supermarket that only sells really good stuff. That's all organic and all this and that.

00:39:14.860 Do you think this gets sold by the market or not?

00:39:16.800 So this is complicated because you can't disentangle politics from this. And I think it's,

00:39:28.540 it's very counterintuitive to people, to myself included, how non-linear the effects of agricultural

00:39:36.520 subsidies are on what we ultimately consume. Now, if, if I were czar, what I would, but I also had

00:39:47.560 infinite time where I could do multiple experiments. So I had kind of like a parallel universe.

00:39:52.020 The first thing I would do is just see what happened when I removed all crop subsidies.

00:39:58.500 I don't believe that's the answer, by the way. In fact, I don't think that will get us where we want,

00:40:02.720 but it will perturb the system enough. And I would really like to see what would happen,

00:40:06.780 right? So right now in the U S corn and soy are the dominant crops and they are heavily subsidized.

00:40:14.540 Of course, corn is the backdrop for most sugar, right? Most sugar in the United States is not

00:40:20.860 cane sugar. It's high fructose corn syrup, obviously derived from corn. I would be very curious to just see

00:40:27.780 what the economic ramifications would be of a complete elimination of subsidies.

00:40:34.220 Then what I'd want to do is perturb the system further in the direction that I would want things

00:40:39.520 to go, right? Everybody knows, you know, show me how a person gets paid and I will show you how they act.

00:40:47.080 And so if we wanted to create a state where fruits and vegetables, whole foods,

00:40:53.820 you know, regenerative agriculture as a concept, which we didn't talk about, but we could

00:40:59.240 became the norm, which meant it wasn't just available to rich people in Beverly Hills,

00:41:04.400 but it was available to everybody, right? Anybody who was trying to put food on their table could

00:41:09.980 acquire this food. What would have to be true? And I would basically work backwards from that desired

00:41:16.900 state to what are the economic incentives that need to be in place? So in this sense, even though

00:41:23.240 I don't, I think many people don't like the idea of the government putting their finger on the scale.

00:41:28.940 I think this is one of those examples that, as you said, if you just let capitalism run amok,

00:41:34.200 it's going to purely maximize profits and it has no consideration for the externality of human health.

00:41:40.000 What I think instead we want is modified capitalism. We want all the tools of capitalism

00:41:45.440 and the innovation, but the government probably needs to have their thumb on the scale in a way

00:41:49.880 that puts a guidance system on that missile. And currently that guidance system is broken.

00:41:57.400 And I believe it's in large part due to how food is subsidized today. I would just want to do the

00:42:04.540 experiments of changing those subsidies in a way that would produce a different desired outcome.

00:42:10.300 So, and that's not a satisfying answer because I'm not telling you what those changes need to be,

00:42:14.820 but it's a, because I'm quite ignorant of it at this point. Uh, and B, I'm not sure anybody fully knows.

00:42:21.600 And so if we look at, for instance, type two diabetes and you talk about it in the book. Now,

00:42:28.240 when I think about type two diabetes, I go, Oh, someone's just quite big that it needs to be dealt

00:42:33.680 with and blah, blah, blah. It's not a big deal. But you argue something else in the book that this

00:42:38.400 is a very, and it actually opened my eyes to the dangers of being obese and morbidly obese.

00:42:45.080 And there is a whole host of issues that come with this particular condition.

00:42:49.600 Yeah. So in the book, I talk about the four horsemen of death. Um, and the reason I talk

00:42:54.540 about them is that anybody who's listening to this podcast, like they're probably going to die from

00:42:59.480 one of the four horsemen. There's about an 80% chance. If you're listening to us right now,

00:43:03.120 you're about to die. And so, um, and part of that is due to the success of medicine 2.0,

00:43:11.400 right? Like you're not likely to die giving birth to a child anymore. You're not likely to die of

00:43:18.380 an infection. You're not likely to die of cholera. You're not likely to die of influenza. Like the

00:43:23.820 things that killed our ancestors 200 years ago are not the things that kill us. So now we die of

00:43:29.020 cardiovascular disease and cerebrovascular disease, heart attacks and strokes, cancer,

00:43:34.180 dementia, and neurodegenerative diseases, and these cluster or spectrum of metabolic diseases

00:43:41.140 that include everything from hyperinsulinemia, uh, insulin resistance, obesity, fatty liver disease,

00:43:49.260 and type two diabetes. Now, what's interesting is that that fourth horseman by itself doesn't kill

00:43:54.780 that many people. So if you, if you actually just look at death certificates and say how many people

00:44:00.780 on it has, when you, it's really funny filling out a death certificate is a complicated, it's much more

00:44:05.100 complicated than you would think. You have to list the primary cause of death and then all the

00:44:09.420 contributing factors. Uh, and it's very, you have to be very, very technically correct when you do this.

00:44:14.020 So if you were to just look at the 2.6 million death certificates that were filled out last year in the

00:44:18.540 United States, very few of them would have type two diabetes as the number one proximate cause of death.

00:44:24.780 It's when you look at how many of them have cardiovascular disease, cancer, dementia,

00:44:30.280 all these other diseases where a contributing factor is indeed type two diabetes. And the reason

00:44:35.400 is type two diabetes contributes so much to each of those diseases by effectively doubling your risk

00:44:42.860 of each of the other three horsemen. In fact, if you have type two diabetes, your risk of all cause

00:44:49.140 mortality goes up about 40 or 50%. That means if you take an individual with type two

00:44:54.640 diabetes, their risk of dying in the subsequent year from any cause is 50% higher than someone

00:45:01.900 without type two diabetes. And do we know the reasons for that?

00:45:06.620 Yeah. We think that the majority of it comes down to what happens when glucose is dysregulated because,

00:45:14.060 you know, that's what type two diabetes is. It's a disease of glucose dysregulation.

00:45:18.100 It's a mismatch between how much glucose is in the bloodstream and how much that person is able to

00:45:25.120 dispose of it, which is just a technical word for put that glucose into their muscles and into their

00:45:30.420 liver and keep their blood glucose levels normal. And if the blood glucose levels are elevated and they

00:45:36.200 don't have to be elevated very much, I mean, to put this in perspective, the three of us are sitting

00:45:40.540 here right now talking. We probably have a grand total of five teaspoons of glucose in our entire

00:45:47.620 circulation. That would be normal. If that number were increased to seven from five, we have type two

00:45:55.560 diabetes. Wow. I mean, it's a subtle difference. In other words, the body's capacity to maintain

00:46:02.060 homeostasis in this regard is incredible. But what are the consequences of that? Well, the more glucose you

00:46:07.680 have in your bloodstream, the more glucose sticks to various proteins in the body. And that leads to

00:46:13.240 certain issues that result in microvascular damage. So that you've probably heard of people with type

00:46:18.580 two diabetes, they're more likely to have impaired vision. They're more likely to require amputations,

00:46:24.340 get kidney disease, cardiovascular disease, small vessel disease in the brain. And then the other thing

00:46:29.620 that happens is you have higher levels of insulin because you have more insulin trying to put

00:46:33.980 that glucose away. And then higher levels of insulin tend to be more damaging to larger blood vessels.

00:46:40.020 So it's a complicated cascade that involves the elevated levels of glucose, the elevated levels of

00:46:46.160 insulin that initially are made by the body, but ultimately usually supplied by the exogenous insulin

00:46:51.260 that they have to give themselves. And then you have a whole host of other factors, including the

00:46:55.440 inflammatory cascade that comes from the excess adipose tissue, meaning excess fat cells produce excess

00:47:03.340 inflammation, cytokines that also lead to damage of organs. And there was something in the book that

00:47:09.220 I found incredibly fascinating where you were talking about tumors, cancerous tumors, and the effect

00:47:14.860 that glucose had on them. And if you've got excess glucose in your body, I was there thinking, well,

00:47:20.880 what's your tumors are growing basically quicker than normal? Yeah, I think the bigger issue for the

00:47:26.300 cancer cells is probably not even the glucose. Although yes, cancer tumors rely almost exclusively

00:47:32.760 on glucose. It's the other growth signals that come with high glucose, namely insulin. So I would argue

00:47:40.240 that it's the hyperinsulinemia more than the hyperglycemia that is probably the more important

00:47:47.560 relationship link between type 2 diabetes and the increase in the prevalence of cancer.

00:47:54.040 Peter, I want to talk about before, you know, in this interview at the end about some of the answers

00:48:00.020 to these things at an individual level. But before we do, one thing we really want to talk about that

00:48:04.520 you don't talk about in the book is testosterone. We know that men's testosterone is going down

00:48:10.000 generation by generation. First of all, do we know why that is?

00:48:15.920 There's probably a couple of reasons, but the data would suggest that the most dominant explanation for

00:48:22.200 why basically a 30-year-old man today has the same testosterone as a 50-year-old man did about 40

00:48:31.440 years ago. Wow.

00:48:32.640 So that's a demonstrable fact. The best explanation for that is probably the increase in body fat that

00:48:42.360 has come along for the ride in that period of time. And with that increase in body fat comes an increase

00:48:47.920 in inflammation. And with that increase in inflammation, you basically are going to make

00:48:52.920 less testosterone. So it's impairing the body's ability to make testosterone. And then also the

00:48:57.980 other thing that happens with more body fat is more of the testosterone that is made is shunted into

00:49:02.940 estrogen. So the what's called aromatization of testosterone into estrogen is a natural process.

00:49:11.280 But the balance, the more adipose tissue, the more fat tissue you have, the balance of that shifts

00:49:16.300 more that way. There are probably other factors as well, though. For example, we only make testosterone

00:49:21.560 when we sleep. I mean, that's where we have the biggest pulsatile amount of luteinizing hormone and

00:49:27.280 follicle stimulating hormone, which tell the body to make testosterone. So you could argue, although I

00:49:31.940 don't think I have great data for this, that anything that's going to disrupt sleep or degrade quality of

00:49:37.960 sleep, especially deep sleep, might have a negative impact as well. So that could be stress. That could

00:49:43.840 be, you know, phones, things that kind of get in the way of people's lives. But I think that most of

00:49:51.800 this effect is probably explained by the increase in body fat. Really interesting. And the question that

00:49:57.240 I was wondering about with all of that, we know testosterone affects behavior. And you're not a

00:50:05.420 political guy. You don't get involved in this stuff. But I do think it's an interesting question

00:50:08.600 to think about. This must be affecting how people vote, what policies they support, and therefore

00:50:16.440 the culture of our society, right?

00:50:19.460 I honestly have never thought about it that way. So are you arguing that lower, on aggregate,

00:50:25.760 lower testosterone would lead to a shift in one way or the other politically?

00:50:30.860 Well, when people have less testosterone, they show up differently in the world. They respond

00:50:37.460 to threats differently. They care about different things. They feel more powerful or less powerful.

00:50:42.800 They have a different locus of control, all of these things, right? So forgive me for kind

00:50:48.320 of being as blunt about it as I am, but a culture in which sensitivity and, you know, being extra

00:50:54.760 careful and not offending people, et cetera, seems to be taking off, frankly, or has at least done over

00:51:01.260 time. It doesn't seem like much of a leap to go, well, if we all have less testosterone, wouldn't

00:51:07.500 that be the consequence?

00:51:09.040 Yeah, super interesting thought. I never gave it thought. I don't know. You'd have to put it in

00:51:15.620 the context of all the things that change. The other thing is, even though testosterone levels are

00:51:20.920 lower than they've ever been, testosterone replacement is also higher than it's ever

00:51:25.400 been. So what we don't really know is what is the realized level of testosterone today in the

00:51:32.220 population relative to a decade ago or two decades ago when some of these behaviors, you know, started

00:51:39.580 to take hold. Because if natural testosterone is lower, which it undeniably is, but it's being

00:51:45.740 supplemented and corrected, then maybe it's a wash and there are other...

00:51:50.620 But I'm guessing college students aren't taking testosterone replacement, right?

00:51:56.400 I do believe some are, but I don't know how prevalent it is.

00:51:59.580 Yeah.

00:52:00.100 But you get my point.

00:52:01.140 Yeah, it's an interesting point.

00:52:02.960 Yeah. And the other thing I was going to ask you is, this is a question from my wife who wants 0.97

00:52:08.440 me to eat less red meat. It's something that kind of is the universal meme that red meat is bad for

00:52:16.140 you. When I went for dinner at your house, there was quite a lot of red meat on the table from my...

00:52:20.840 Now, Jordan was there, to be fair, so you kind of had to do that. What's your take on that as

00:52:24.940 someone who's very health conscious?

00:52:27.000 Yeah, this is one of those enduring examples of really, really bad science that just never dies.

00:52:35.900 So this idea that red meat is somehow harmful really began its hold during the 1980s when people

00:52:50.840 began to be aware of cholesterol and the role cholesterol played in heart disease. And of

00:52:57.480 course, red meat at the time was being compared to white meat. And so back in the early to mid-1980s,

00:53:04.180 there was really a push to move people away from beef to chicken. And the idea was, well,

00:53:09.980 chicken contains less saturated fat and therefore, on balance, you would have a lower level of

00:53:16.660 cholesterol. And that's true depending on how much of it you eat. What has given that idea more legs

00:53:25.060 is some of the epidemiology that has demonstrated, though not consistently, that people who eat

00:53:31.720 red meat have higher risks of, you know, type 2 diabetes or cardiovascular disease than people who

00:53:38.080 avoid red meat. So on the surface, you might be listening to this and thinking, well, that seems like

00:53:42.740 a case closed, no-brainer. But the problem is epidemiology, especially when the hazard ratios are

00:53:49.100 relatively small, is so fraught with errors, right? Epidemiology only identifies associations,

00:53:55.360 but it can never identify causation. And so one of the biggest challenges with the red meat

00:54:01.280 epidemiology stuff is that people consuming red meat and people not consuming red meat tend to be

00:54:08.420 proxies on average for very different behaviors. So for example, people who consume red meat on average

00:54:15.920 will tend to consume more processed foods. In fact, much of the red meat that they consume is in the

00:54:20.760 form of processed red meat, like, you know, gas station jerky sticks and things like that.

00:54:25.300 People who go out of their way to avoid red meat tend to engage in many behaviors that are pro-health.

00:54:32.560 They tend to exercise a lot more. They smoke a lot less. They engage in other food behaviors,

00:54:39.520 such as the consumption of fruits and vegetables, to a much higher extent. Now, what's interesting is when

00:54:45.040 you strip all of those things away and you normalize for, say, vegetable consumption,

00:54:50.480 that cancer-causing effect of red meat completely vanishes, right? So in other words, when you just

00:54:56.840 say, let's compare people who eat red meat to people who don't, you're going to get that difference in

00:55:01.580 risk. But yet when you start to correct for everything, including servings of vegetables in a day,

00:55:07.780 all of a sudden the harm, the supposed harm of red meat goes away. I think there's more nuance to it

00:55:13.480 than that, frankly. And I think it also comes down to the type of red meat you're going to consume.

00:55:17.620 And I don't think all red meat is created equal, just as I don't think all plants. We've already

00:55:21.460 talked about how in Europe, there's clearly something different between the bread and pasta

00:55:26.560 in Europe and the bread and pasta in the United States. And it's not a stretch to assume then

00:55:31.420 that not all meat is the same. And I don't, you know, I mean, so much has been said about it.

00:55:35.380 I don't need to harp upon it, but I think there's a fundamental difference between consuming

00:55:39.140 farmed red meat and consuming, you know, grass-fed red meat that is free of antibiotics and hormones.

00:55:46.220 Now, again, this gets back to a problem you raised earlier, which is that's a great thing to say when

00:55:51.040 you're, you know, well-to-do enough that you can afford to buy those things and not everybody can.

00:55:56.280 So that said, I still think that the majority of the literature condemning red meat is highly flawed.

00:56:05.480 I would say that if a person consumes red meat, they should probably make an effort to

00:56:10.140 invest a little bit more and get the red meat that's probably of the highest quality. 0.98

00:56:14.140 And this may be an incredibly stupid and factually incorrect question, but I have 0.95

00:56:18.520 heard a lot of talk and read a lot of talk about the fact, the idea that actually there are several 0.99

00:56:24.920 types of human beings and some are supposed to eat meat and others are not. Is there any truth to

00:56:31.520 any of this? I have a really hard time kind of accepting that. I mean, I think the basis for

00:56:37.380 that line of reasoning stems from the fact that, you know, you can trace our ancestors to different

00:56:44.580 parts of the globe, right? So my ancestors all came from Africa. Yours came from Northern Europe.

00:56:50.660 You know, there's someone whose ancestors came from Asia. And the idea was, well, my ancestors would

00:56:55.340 have ate more of this and less of it. And therefore, would I be more naturally suited to that?

00:57:01.660 Again, I've just never seen compelling evidence to support what is otherwise a very lovely story.

00:57:07.740 And so before we move on to our final question, there's the average person who's sitting there

00:57:13.460 watching this or listening to this and they're thinking, right, this is really interesting and

00:57:17.260 this is great, but how do I become healthier as a person? What can I do to improve my health and to

00:57:24.140 live a longer and most importantly, not just longer, but as you said in the book, healthier life?

00:57:30.400 Well, it's actually interesting. It's the one thing we didn't talk about today. I mean,

00:57:33.140 we did a lot of things we didn't talk about, but I think the most important thing that we didn't

00:57:36.420 talk about, but it's okay because there are three of the 17 chapters in that book are about it,

00:57:40.320 is exercise. And I think that... Yeah, let's not focus on that. What else can I do? No,

00:57:46.380 I'm joking. Carry on. Honestly... Well, I have to make an effort. God, no, no.

00:57:51.240 Well, but for some people, myself included, food requires more effort than exercise. So

00:57:57.260 everybody has their own cross to bear in this regard. And for me, food is the biggest cross

00:58:02.500 to bear by far. Sleep comes naturally to me if I do the right steps, meaning it comes naturally to me

00:58:08.460 to be disciplined about sleep hygiene. It comes very naturally to me to want to exercise. I get the

00:58:14.260 reward in the short term of actually feeling good. And for whatever reason, it connects with my

00:58:19.600 cognition where I can tie my ability to do something now to what I did in the gym yesterday.

00:58:26.240 But food is very difficult. Food is a never ending struggle for me. If left to my own devices,

00:58:31.380 I would eat French fries, Kentucky fried chicken and pizza all day, every day. I love it so, so much.

00:58:38.420 You two would get on.

00:58:39.160 Yeah, we do. You know, you should come around one time, Peter. Let's just go.

00:58:42.840 Do you know, the last time I was in the UK, I made a point to have fish and chips every single day.

00:58:49.380 I was like, you know what? I'm only here for a week. Like, I'm just going to go to hell.

00:58:52.520 You absolute psycho. 1.00

00:58:53.440 Yeah. You see, and that's why you're here. 1.00

00:58:56.620 There's a connection.

00:58:57.480 You couldn't stop eating fish and chips. Couldn't stop. But I think that the majority of the health

00:59:06.560 span benefits that we speak of, both mind and body are going to come from exercise. So if I could,

00:59:12.300 if someone said, look, Peter, just direct me to one thing, I would direct them to, hey, read the

00:59:17.640 chapters on exercise and figure out a way to sort of balance your exercise portfolio around the right

00:59:24.300 amount of strength training, the right amount of cardio training, the right amount of movement

00:59:29.600 training. And I think that that's, on a singular level, going to pay higher dividends.

00:59:35.620 It's been a fantastic interview. Thank you so much for coming on the show, Peter. Final question

00:59:39.840 is always the same. What's the one thing that we're not talking about that we really should be?

00:59:44.720 Yeah. Even knowing you're going to ask that question, I still can't come up with a great

00:59:47.860 answer. So I would say, what's the opposite side of the AI bet when it comes to health, right? So

00:59:55.060 most people that are talking about AI as it pertains to health are taking, I would say,

01:00:02.680 the most optimistic view, right? Which is, and let's give them reason for saying that, right? So

01:00:09.460 at the time of our recording, a Nobel Prize was just awarded. The Nobel Prize in Chemistry was just

01:00:15.640 awarded to the folks at Google that developed AlphaFold, right? So this was a remarkable AI

01:00:21.880 technology that did something, I don't know, if you told me this was possible two years ago, I would

01:00:26.940 have said, I don't think so. And I would have been wrong, which is, and this is nuanced, but it's an AI

01:00:34.220 that was able to predict the folding structure of a protein only knowing the primary sequence of amino

01:00:39.880 acids. And you might say, well, why is that interesting? Well, that's interesting in that it's a much,

01:00:44.120 much quicker way to help scientists predict what type of molecule would fit into a receptor, and

01:00:52.140 that's effectively what pharmacology is. So that now takes the first step of drug discovery and makes

01:00:57.980 it really, really fast. So based on that, I think many people are now saying, in 10 years, we are going

01:01:04.620 to be immortal. Because when you have an AI that can solve that problem today, and you look at the pace

01:01:11.340 at which AI is growing, what is it going to be solving in 10 years? It's going to solve aging. So I've met with

01:01:17.920 many people, some of whom I think are incredibly intelligent, who say, look, in 10 years, it doesn't

01:01:23.120 matter. Just don't die for the next 10 years, and it's all going to be okay. Because in 10 years, AI will have

01:01:28.020 solved death. And I think while that might be a slightly extreme view, virtually everybody I talk with in

01:01:35.700 healthcare says, AI is going to completely change our lives for the better with respect to health.

01:01:43.180 And I just think it would be interesting to hear the bear case on that. And what's the less optimistic

01:01:48.060 case? Not that AI is necessarily harmful, but that aging is a much more complicated problem than some

01:01:53.480 of these standard engineering problems. And while what AlphaFold did is incredible at the chemical level,

01:01:59.260 it still doesn't solve, like, how do you unfold proteins in my body that have folded irreversibly?

01:02:07.860 So we should keep drinking our own urine for the meantime.

01:02:11.180 Exactly.

01:02:12.880 To stave off aging.

01:02:14.040 Just take the hedge, assume that, yeah. Keep exercising, yeah.

01:02:18.060 I literally can't think of anything worse. I actually would rather die than drink my own urine

01:02:23.200 for the rest of my life. Peter, I don't know why we ended on that. Thank you so much for coming on the

01:02:27.680 show. It's been absolutely awesome. I would, not only would, I actually do recommend your book to

01:02:32.260 everybody because it was so transformational for me. It's really, really, I really hope more people

01:02:37.640 read it because, as I said, I was somebody who was not paying too much attention to my health. I was

01:02:42.820 busy with work. I sort of thought I was very healthy anyway. It's been genuinely eye-opening

01:02:47.260 and transformational. I think if more people read it, the world will be healthier. So all power to you.

01:02:53.140 I hope people buy Outlive and read it. It's a fantastic book and keep up the great work.

01:02:57.120 Thank you so much, guys. Appreciate it.

01:02:58.600 All right. Head on over to Substack where we ask Peter your questions.

01:03:03.480 Do you have any suggestions for legislators or educators who are trying to break the insatiable

01:03:08.860 appetite for sugar, fat, and salt, especially in lower-income groups?

TRIGGERnometry - January 08, 2025

The Truth About Ozempic, Sugar and Big Food - Dr. Peter Attia

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