Dr. Peter Attia: Improve Vitality, Emotional & Physical Health & Lifespan
03:25:02 Share

Welcome to the huberman lab podcast, where we discuss science and science space tools for everyday life. I'm Andrew huberman and i'm a professor of neurobiology and optimal gy at stanford school of medicine today. My guest is doctor Peter itea, his second time on the podcast.

dr. Peter ita is a medical doctor who did his training at stanford school of medicine, johns hopkins school of medicine and the national institutes of health. He is a world expert in all things related to health spin, vitaly and longevity.

In this episode, we focused on many topics, focusing mainly, however, on health spin and longevity and mental health. Health spin and longevity, of course, relate to how long one lives. And doctor ita goes systematically through the seven major causes of death worldwide, beginning with cardiovascular disease and cerebral vascular disease, also cancer, also accident related death, dementia, death of despair.

And in every case, explains the three or four major leavers that one can employ in order to offset that is to prevent those major causes of death. What follows is an incredibly informative and actionable set of tools for anyone, male, female, Young or old. He explains the behavioral nutritional supplementation based and prescription drug based approaches that one can use in order to extend health in and longevity.

Doctor ity explains the key test and markers that we should all pay attention to if our goal is to extend our health bin and how to do so while maxims ing our vitality. This is something that not a lot of people think about when they think about health, spin and longevity. But as doctorate IT illustrates for us, emotional health has everything to do with our physical health, and vice versa.

And he shares quite openly about his own experiences in pursuing ways to improve emotional health, and thereby, health span, lifespan and vitality. Doctorate is quite open about his own experiences, expLoring different practices to improve emotional health as ways not just to improve health band longevity and vitaly, but of course, also to derry, the most meaning and satisfaction from life. Throughout today's discussion, we also discuss doctor teas newly released book, which is entitled outlive the science and art of the longevity.

This is a phenomenal book. I've read IT cover to cover now three times. I have extensive notes written throughout, and the book, of course, focuses on longevity and health span, and also has an extensive section on emotional health, gets quite detailed into dr.

Ty as personal experiences with emotional health and tools to improve emotional health that are very actionable for anybody to use. I think the best way for me to summarize my feelings about the book would simply be to read the book jacket quote, which I provided, so I read, quote. Finally, there is a modern throw, clear and actionable manual for how to maximize our immediate and long term health, firmly grounded in data and real life conditions.

This is the most accurate and comprehensive health guide published to date. Outlive is not just informative. IT is important and indeed, outlive is an important book, as is the discussion the doctor T.

A so graciously provided us in today's episode. Outlive is released on march twenty eight, twenty twenty three, and is available for period prior to that date. You can find a link to where it's sold in the shoote captions.

Before we begin, i'd like to emphasize that this podcast is separate from my teaching and researchers at stanford. IT is, however, part of my desired effort to bring zero cost to consumer information about science and science related tools to the general public. In keeping with that theme, i'd like to thank sponsors of today's podcast.

Our first sponsor is element. Element is an electronic drink with everything you need and nothing you don't. That means plenty of salt, magnesium in patashie, this so called electronic and no sugar.

Now, salt, magnesium and potash are critical to the function of all the cells in your body, in particular to the function of your nerve cells, also called neurons. In fact, in order for your neurons to function properly, all three electronics need to be present in the proper ratios. And we now know that even slight reductions in electronic light concentrations or dehydration of the body can lead to deficits. And cognitive and physical performance element contains a science back electronic light ratio of one thousand milligrams, that one gram of sodium, two hundred milligrams of paci um and sixty milligrams of magnesium.

I typically drink element first in the morning when I wake up in order to hydrate my body and make sure I and of electro lites and while I do any kind of physical training and after physical training as well, especially if i've been sweating a lot, if you'd like to try element, you can go to drink element that's element t dot com s slash huberman to claim a free element sample pack with your purchase. Again, that drink element, element dot com slash huberman. And now for my discussion with doctor Peter, a tea doctor, a tea Peter. Welcome back.

Thanks, man. Good to be back and sounding this time.

Looking forward to talking about a number of important topics with you that you cover in your book. Maybe we could start off by trying to set the frame for what people should be thinking about in terms of vitality and especially long gravity.

So I mean, I think you have to be mindful how you define these terms. And um i'm not you going to suggest that the way I define them is the only way or nessa the best way. But I think from a clinical perspective, it's the way that makes them a sense to me, having thought about this for the Better part of a decade.

So IT involves some by vacation between lifespan and health span. Lifespan is very easy for people to understand. IT is binary. You are alive or you are not alive. And clearly part of longevity is about how long you live ah now I think for a lot of people that tends to be where the discussion ends.

That tends to be the focus of IT right at sort of like longevity somehow implies living for no one hundred years, hundred twenty years, something to that extent we talk a lot about maximum lifespan um even in laboratory experiments with mice, that sort of one of the metrics that that disgust is what what's maximum lifespan of the animals um but there's an equally, if not slightly, I think potentially more important part of longing. Vy, which is health span and healthy bin is squishier. And I think IT requires some definition.

Now the medical definition of health span is the period of time by which you are free from disability and disease. I find that to be a not particularly helpful definition because by that definition, you and I have the same health span today that we did thirty years ago. But I know you pretty well.

You know me pretty well. Thirty years ago, we were twice the men. We are now based on what we believe our health span is right in terms of our cognitive function, our physical performance and things like that.

So you i've clearly experienced the deteriorating my physical functions, as i'm sure you have going back to when you were a teenager late, teenager early. And I think that needs to be captured somehow in health spin. So the way I think of health span really is along these three dimensions, physical, cognitive and emotional. Again, not necessarily suggesting that that's the only way to do IT, but I do think that clinically IT makes the most sense. And so therefore, anything that really becomes a question of longevity has to address all of these issues, lifespan, physical health beyond that of just straight up disability in disease, cognitive health, independent of and separate from pathology such as dementia and emotional health, which of course, is by far the most complicated of all of these because we have no biomarkers for IT. We have no you know it's not like you can get a scan on somebody and determine the state of this um but nevertheless, it's it's important right in the dramatically factors into quality of life.

So with all of that in mind, what are the major exit points for people along the life span route? To start with the the binary one day alive? You right? I think most everyone whose healthy would like to be alive rather than dead. So what are the typical ways that people exit from alive to dead? And uh how can people stay on the a free way of life?

So speak so this is again a great analysis. We internally uh in our practice call this the death bar analysis and its a surprisingly trivial analysis that i'm just surprised the death bars aren't plaster front center on every doctor's office um so if you simply just look at actuarial data, which are readily available through the cdc and do a little bit of data manipulation in an alysa, you can pretty quickly realize what the horseman of deaf are because there is largely speaking, kind of four horseman of death.

Um the first and most consequent in terms of the numbers is the diseases of authors' rosas. So that's um cardiovascular disease being a lion and share of that, but also the removal lar disease. So anything that has to do with arthritic rosa rises to the top.

Now that's that's true in the united states, but it's even more true outside of the united states, is even more true globally. So one of the words, when you look at the relative difference between the number one cause of death in the U. S.

And number two which is cancer, um the gap is actually smaller in the us. And globally. Globally it's enormous. We're talking about eighteen to nineteen million people a year that are dying a athor scarcity cardiovascular disease in the world. Where is number two is cancer at about eleven million?

How does the number change when you include um three of vascular disease?

Yeah I adit adds a bit to IT three of assured disease has there's largely speaking you can die sort of through emboli c events which are the majority of them explain .

for people at what embodies events are.

yeah, so taking a step back, what what does the brain need more than anything that needs blood flow, anything that interrupts blood flow to the brain that results in a schema is, uh, devastating. And it's devastating in a more readily apparent fashion and virtually any other organ. Um so one way that that can happen is if a quote or disruption of blood flow occurs through obstruction of blood clot sop, so that can OCR through a lot.

So for examples of person as atrial fair relation and a blood clot gets festering in the right atrium, and they happen to have a hole in between the the atrium of their hearts called the painting for in a valley, and a clock goes from right to left, IT can make its way up into the a arterial circulation and happen that way where you would club love. Though the much more common way IT occurs is the same way IT occurs in the heart, which is, you have black build up and that black becomes unstable, that black ruptures. And the rupture of that plug results in an immediate attempt by the body to fix the problem.

But in doing so, IT walls off the artery, meaning the blood floor of dispute to that point. So you know, now blood is acutely being robb of that. However, there are other ways that people can um have this problem. And so you have the whole hammer radic side of this, you can have blood vessels that you know small blood vessels in the brain that will rupture as a result of high blood pressure, for example. So hypertension factors both into both sides of this equation um both in the heart and in the brain and the majority of these are embolization wever so don't quote me on this exactly but call IT four or five to one strokes result from an emma lic phenomenon as opposed to a hema gic phenomenon, a bending phenomenon.

I don't want take us too far off on attention, but as long as we're here talking about bleeds diverse s clots, what are some of the major risks for bleeds? I mean, I know some people out there have etic previous positions for being bleeder as there sometimes called or clutters. So things like a factor five lighten mutations um which can be exacerbated women, for instance, by taking certain oral contraceptives I mean and there's hugeous if people are interested in them, they can look up water the factors uh controlling bleeding and pretty expose people to be in quarter. But for the typical person out there who feels healthy um but might do well to know whether not they are pretty posed to be a bleeder or a claude, what what sorts of things rise to the top of that list and and that people might want to check into well um I mean.

there might be sort of two different things going on in that question but I think if your question is when we look at the subset of people who at highest risk for hema gic strokes, the far more german question is not underlying hoeg oaths. The far more germaine question really comes down to blood pressure. Blood pressure would be the first, second and the third driver of that. So hypertension is hands down, the leading driver of hemorrhagic stroke phenomenon OK.

So i'll just a briefly interpret and ask since sometimes your recommendations deviate from the the standards that one would find online or in the typical doctor's office, at what point you get concerned?

Well, I I actually find myself quite in line with the most recent available data on blood pressure. And this has been um obviously is a topic that's a high concern to any doctor who's taking care patients who even pays a fraction of attention to the available literature, which is that basically with each subsequent blood pressure trial, the data are becoming clear and clear that the more aggressively you manage blood pressure to be within the one twenty over eighty range Better.

So there's a recent study that even looked at going from what used to be considered acceptable, which was one thirty to one to thirty five over eighty eighty five. We used to basically say that's kind of the first level of hypertension. And we would say, well, do you really need to be Better than that? And the answer turns out to be, yes, you do.

If you want to reduce heart attack and strokes, be, it's Better to be one twenty over eighty than one thirty five over eighty five. Now this is a whole other rabbit, all that we don't need to go down, but it's a total obsession of mine, which is, how do you measure a person's blood pressure? I think this is potentially, I have to give IT thought.

But on esty, I could say top three underdiagnosed fixie problems in the united states today and probably globally in other are too many people walking around with high blood pressure who don't know IT. Um and I think part of the problem is it's something that is mostly done in the doctor's office and the reading that you get in the doctor's office can be often misleading. You ve heard this phenomenon of White coat hypertension. So you go to the doctor, your blood pressure is virtually never measured correctly.

In the doctor's office, that cough they put on and tweet.

You look at the river with, you need to measure a person's blood pressure. The right way to do IT is the person has to be sitting like this for five minutes.

doing nothing OK folk. So when you go .

to the doctor, you don't them .

sitting five years. And that doesn't include in .

the waiting room because you .

make them stand there.

So to sitting there like this, um a manual cuff is Better than an automated cuff. But not enough people use manual blood pressure. So a manual blood pressure means they put a cup on you and they actually put a death scope on the brake of artery.

And they are, you know, using the human ear to listen, which believe or not, you would think a machine is Better, but it's not. The machine can be misled by different sounds. I don't want to suggest that automated cubs are useless.

They're not. But when an automated cuff gives you an answer that is, you know, potentially suspect, always back IT up for the manual, i'm pretty relentless about checking my blood pleasure. And so i'll do side decide manual verses automated every day, and there is easily attend to fifteen point difference between them.

Maybe there's a silly question, but can people check their own .

blood pressure up, meaning manually?

Yeah just could I could I get get a woman and learn how to do IT?

Yeah I think I mean, I can do IT but honestly, you usually my wife do IT she's a nurse um but it's not rocket science. Check check blood pressure. I've guarantee you there's a great video on youtube that explains the physical ology of IT. And if you're willing to splurge on a good enough death of scope and the cough I have is really easy to use like it's once you put IT on, you know it's in a single thing. I'm squazing the bulb and looking at the pressure gage while i've got the you know um stuff scope on my artery.

I me given the importance of blood pressure and this articles clarus as being at the top of the list of uh risks for um dying um IT seems to me that might be worthy expense a typical range of cost for .

for the quality of you box um and the death scope is a couple hundred box if you're getting a good one and um you know good automated cfs there's I I have no affiliation with that these companies I use. I use two automated cuff once called wings and the other ones made by a company called ARM run O M R O N um and they're both decent. But again, they tend to run high.

And I have yet to find a credible explanation from cardiologist as to why everybody acknowledges that the manual one went done correctly is the answer. But i've heard monkey answers about why automated ones are sometimes incorrect. And again, it's just made me realized we're not checking blood pressure off and enough on people. We're overly relying on blood pressures in the doctor's office, which are not being done correctly. So we basically have our patients do this relentlessly.

So how often let's say, someone buys this because I think for two hundred and forty dollars, I mean, I realized that's prohibitive for some people. But given the cost of some of the other things they are discussed on this and many other people.

I would just like people start with an automated cuff to begin with. I can start with there. Um we generally have people do IT for two weeks. You know we give our patients a little spread ed sheet that automatically calculates averages and stuff like that tells them what to record and where. And we just say, look for two weeks, we want to see two recordings a day and you know do in morning and an afternoon slash pm recording twice a day for two weeks and um let us see those numbers and will screen nize them further. And if those numbers come in, fine, let's revisit in a year.

Will a day ever come when as a watch or a response can do this really well?

So um I hope so. And i'm investigating IT. I am actually gonna be trying one out in a couple of weeks with a company that I tried two years ago.

Two years ago when I tried that, I was not impressed. So I kind punted on IT. Um the company, which I guess i'll not sure the name of the company just see that.

But they they claim that is significantly Better. So i'm going to put IT to the test again and it's basically a continuous monitor. So it's it's a risk device that about every fifteen minutes throughout the course of the day will check your blood pressure. Um to me this would be I honestly probably more important you know you know how much emphasis I place on cgm as a great thing to be able to test cost, right?

I would argue this would be more important when the day comes that we can continuously people blood pressure um IT would be an integral part of a person's you health check up once years due two weeks of continous bad pressure monitoring right now to do that, which i've done as well, is so cover some that IT borders on absurd. You actually have to wear a blood pressure cuff that is attached to a clumsy device that goes through the whole insufficient ery SE every fifteen minutes, including while you're sleeping. You know IT provides some insight, but it's so disruptive that is not what we really want, what we the dream would be like a patch that you could put, I don't know, over your chest that can somehow compute changes in blood flow or something like that and regulate. But um we'll see you know between optical sensors and things like that. I hope that we're getting closer to having something.

So I don't want a stroke, I don't want to bleed in the brain and I want a clock as long as we're at this number one on the list archives, chloro is being the number one killer. What are the major ways to prevent IT? yes. So there's .

three big ones that stand out, you know top and center. And then there's of a fourth one that I think is the the foundational piece. So the three big ones we ve talked about, one blood pressure.

So if your blood pressures one twenty over eight year Better, that's important. The second is not smoking. So IT turns out that smoking and blood pressure are both devastating for arteries uh, but for different reasons, right?

So smoking is devastating for a chemical perspective. So it's completely irritating to the endothelium. So the endothelium, as you know, is the single cell lining that is the inner most part of the arterial and arterial wall.

So this is a pretty special organ. Um again it's it's a bit naive ve but understandable that people just think of arteries tubes. They're much more complicated than that. They have many layers to them, but this particular layer is unusually important. IT hasn't outsized importance because IT is the one that's in contact with the luminous side right where the blood is flowing in the tube, and anything that injuries that has significant consequences. So smoking is irritating to that in a chemical way, and blood pressure is irritating to that in a mechanical way. So those two things, basically, you just want to, that's the low hanging fruit in my world, right? You just don't want to have those things causing irritation to the indefinitum because that renders you now suspected to the third factor, which is A O B bearing, like the proteins .

I wanna talk about apple, be in depth, but as long as don't smoke is the second recommendation on the list? Or can we Better define um smoking and what's being smoke? So as you nicot for what about canvas and what about of nicotine and cannabis because vapor has become so much more common yeah it's a .

great question and it's sadly something we don't have a great answer for. So I can certainly tell you that there is no reason to believe that smoking cannabis is somehow Better than smoking cigarettes, but the dose seems to be significantly lower. In other words, you know, let's consider a person who smokes a pack a day for twenty years.

We call about a twenty pack year smoker. Someone who smokes two packs a day for fifteen years is a thirty pack yer smoker. That's a person dramatically increased the risk of uh, many cancers, including lung cancer, and also the risk of cardio accused and three proof as collar disease.

Again, i'm not a not A T hc guy, so I don't I can't necessary speak for the habits of people that are smoking marijuana. I can't imagine they're smoking that much. Probably not yeah so so well on a on a joint to cigarette basis, they're probably equivalent in terms of harm.

I don't know. Let's say a person smokes a joint a day that would be like smoking a cigarette a day. That's a twenty years of a pack.

Again, I don't anna say that there is no downside to that, but it's probably significantly less. So I I don't think the risk fully tracks. I think the same is probably true for raping.

And I want to be clear, like I don't think vapor is a good idea. You know, the last time I looked at the data on this IT was surprisingly sparse. But to me, the only advantage I could see to raping was if I was the only way a person would stop smoking.

So there was, I sort of looked at IT, as IT was the definitely the lesser of two evils. But the, by far the Better scenario, I was not to do any of these things. If if nicot is what you're after, there are Better ways to get nickel, for example, through law, anges and gump and things like that, so that you shouldn't be turning to those things to do IT. But but if I was like, if gun is here and cigarettes are here, you vapor was probably here. But boy.

I don't know for those listening A A Peter space his hands far apart for um gum and smoking and put raping about a third of the way we a from gum uh tod uh smoking in other words vpc isn't good for you but it's not as bad .

as smoking that me do you you probably look into this as well piso's nick.

I did episode on cannabis and um you know that the discussion around cannabis gets low contentious for reasons that are um importance.

We have funny people the moment someone starts to confront cannabis as a potential health farm people say it's not as nearly bad as alcohol which is a crazy argument right getting hit by a bosses and nearly bad is getting hit by a motor ycl in most cases but sometimes, you know so that's just kind of silly um and clearly cannabis has medical applications yeah here clearly. And then IT becomes an issue of the ratio of T H to C B D. peer.

C B D forms actually been quite effective for the trees and forms of apple epi. So charleys web that he was called very high. T, H, he containing cannabis, clearly predisposes, especially Young male, to, later on, its psychosis.

Those data starting to become clear, clear enough to me anyway that they bought to be aware of them, at least maybe make decisions on the basis of those when IT comes to the smoking versus vapor is just very, very apparent that the chemical constituents of the type and what people are inhaling are terrible for people and are load with car stains and a bunch of other stuff, many of which, ross, the blood brain barrier. So that's what worries me. Anytime I hear about small molecules, know these small inorganic molecules getting across the building there, and then being maintained in neurons for many, many years.

I worry because the experiment is ongoing mostly in Young people. So anyway, without going too far down that track, I I think if people can avoid smoking and vapors, they should. And as you mention, there are other delivery devices for nicki and cannabis teachers, patches and h gums and things that um edibles that um if people choose to use those .

substance, sometimes people would benefit to imagine what the surface area of the lung is, right? If you took the albula aircars of the lungs and spread them out, you would easily cover a tennis court, remarkable. So now just think about anytime you inhale something.

You are exposing your body is so adept at absorbing IT. I mean, we have this unbelievable system for gash exchange that was designed for gas exchange. And anytime you're putting something else in that way, you're doing a really good job of getting IT into your body.

So be mindful of what that is um and and that look that applies to to pollution to I mean the pm two point five data pretty good I think once used. So particulates that are less than two point five microns are are getting straight into the body um which is not a great argument for avoiding air pollution, right? I mean, I we find IT funny not to get off on this tension, but to me, the most compelling arguments around cleaner energy have nothing to do with Greenhouse gases.

They have to do with air pollution. I promise you more people are dying from the particulate matters in air that result from burning coal that are ever going to die from the C. O.

Two emissions that result from that. It's and I would argue that's going to be two waters a bag. youtube.

It's not even in the same of code makes sense during the fires would seem to follow me 啊。 Because when I was in northern alive, nia to fires were constantly looking to wake up in the morning. Everything was covered with ash.

My dog was having trouble breathing. I was having trouble breathing, everyone was suffering. But there are websites that one can go. You can just look at air pollution here and and we tend to only do this during fires and then you know when southern california to be fired here. So um no, it's a correlation, not causation.

But for sure I input those fires, but it's clear that IT disrupts your breathing for a very long period of time. But it's the long tale of that that we really talking about her the very small particulate that we know firefighters, for instance, in certain industrial workers can end up with that stuff embedded in their brain tissue for extremely long periods. Just not good.

Um you make a really interesting point about um the the call for cleaner energy. Can we run that one up to to washington? Set all some of the debates about climate changes by getting straight how this just bypass all all the garbage that um that being speed back and forth and just and basically get to the issue at hand right?

Yeah just just make IT Better for people to not die from the direct consequence.

I'd like to take a quick break and acknowledge one of our sponsors, athletic Greens. Athletic Greens, now called ag one, is a vitamin, mineral, probiotic drink that covers all of your foundational nutritional needs. I've been taking athletic Green since two thousand and twelve, so i'm delighted that they're sponsoring the podcast.

The reason I started taking athletic Greens, and the reason I still take athletic Greens once are usually twice a day, is that IT gets to be the probiotics that I need for good health. Our god is very important. It's populated by that microbiota communicate with the brain, the immune system and basically all the biological systems of our body to strongly impact our immediately and long term health.

And those probiotics and athletic Greens are optimal and vital for microbiology alth. In addition, athletic Greens contains a number of adaptations in vitamins and minerals that make sure that all of my foundational nutritional needs are met and IT tastes great. If you'd like to try athletic Greens, you can go to athletic Greens dot com slash huberman, and they'll give you five free travel packs that make IT really easy to mix up athletic Greens while you're on the road, in the car, on the plane, at sea, and they'll give you a year supply of vitamin d three k two.

Again, that's a letter Greenstock comes slash huberman en to get the five free travel packs in the year supply of vitamin d three k two. So trying to avoid a serious such a difficile word to say much for a neuroscientist arterial school. Rosa, did I get right? Well.

it's athor o which is easier because .

yeah arthroscopic is no there, making life more complicated for myself, typical of me. Okay um so blood pressure keeping IT one twenty eight, one twenty over eighty or Better. Don't smoke, let's just throw and don't.

Vae, sure i'm going to just plant my flag on. Just don't they're other ways to get those things in your system if you really want to get nickey or cannabis in your system. A O B, what's the story with? A O B.

okay. So to explain this, you have to tolerate a little bit of chemistry. Um so everybody's of cholesterol. And A I I certainly devote quite a bit of time in the book to explaining this because this is so important.

And it's definitely one of those areas where I initially received a lot of push back from the editor. And there was a thought that, hey, this is a bit more technical than IT needs to be. But I I think that sometimes you do need to resort to longer dissertations to dispel mythology.

So cholesterol is a lipid IT is a molecule that the body synthesizes. IT is a molecule that is essential for life. So if you cannot synthesize cluster's, you can't live you, you'll die in utero.

So there are rare genetic conditions that prevent the successful synthesis of cholesterol. Uh, you know, embryos that have those mutations do not survive. Okay, so why do we need this stuff? So we need this stuff primarily for two reasons.

First, IT makes up a very important structural component of sell membranes. So as you know, a cell is a sphere. We look at them and think they are circles, but their fears and they're flew IT, right? They aren't just like little perfect, you know, big bowling balls or, you know, balloons.

They actually move and shape and move in these pads, s and this. So what allows cells to be next to each other? And all those they also have channels across all of them.

And those channels are held in place by, among other things, cluster al and Fosters libert. The second thing that makes cluster al so important, IT, is the precursor to some of the most important hormones in our body. So are sex form to stop stran, estrogen, progesterone in addition to gk a corots.

If you look at them, it's really funny. Now people with you looking at, if you google like give me the structure of these things, you're kind like there all basically the they all look really similar and they're all pretty much just templates of cluster. So understandably, when it's something that's that important, the body would leave nothing to chance.

We make all of our own clusters the customer that you eat in food largely relevant. It's terrified clusters. So IT means that has an exercise chain.

It's too bulky to absorb in the gut. So most collect all that you eat in food just goes out your G I track. okay?

So we have this super important molecule that every cell in the body makes. But there's a bit of a problem. There's actually two problems.

The first problem is not every cell can make as much as IT needs all the time. So you have this demand problem. So for example, if you're sick, you're gona need to make far more glue of cortisol.

Your body's response is going to be a ramp up cortisol production to mobilize fuel and do a whole bunch of other things in certain cells like the adrin o gLance are going to be called on to rise to a higher level of performance. And they're not going to be able to make enough courts all so they're going to have to borrow or take clue from other cells in the body. In fact, one of things we used to notice in the ICU, I never knew why IT was happening.

I now know, is the few times I would accidentally order the wrong side labs on a patient in the ICU and also order like a lipid test or something, you would please notice their cholesterol levels were dropping serum cholesterol levels. And I now realized why? Because they were basically just funding cluster to the adrenals to make more of the courtesy.

But they needed to combat whatever they were in the I C. U. For which is usually the most severe form of, you know, stress the body is under.

So you have to be able to transport this stuff. And then the second problem is, as you know, clutter, all being a lipid, is not water soluble. So the the most dominant highway in the body is the circulatory system.

We we can use the lymphatic system and things like that, but for the most part, we use our circulatory system as the highway to move stuff around. And the highway is made up of water. Plasma, which is, which is the liquid component of your blood, is water, and therefore things that are water soluble move easily.

So glue cose sodium electorates. All of those things are dissolvable in water, and therefore they don't need a Carrier. You just dissolve them in the water and they can go.

So that's why your liver can make glue cose that your brain can easily get. And there doesn't need to be a career or an intermediary or anything like that. But unfortunately, with cluster's being a lipid, we can do that just as water and oil don't mix, cluster's and plasma don't mix.

So the body had to come up with a trick, and the trick was designing a vehicle that was water soluble on the outside and fat solvable on the inside, that you could bury the clutter inside, along with strugglers rides. And on the outside, IT was covered in protein, which is water solyman all. And that's the, that's the thing that moves around.

And that thing is called the light of protein. And as its name suggest, it's part lipid, part protein, lip on the inside, protein on the outside. And those lip of proteins come largely in two different families. So one family comes from a lining age called apple b.

So the apple b family, which is short for apple, like a protein b one hundred, is a family that is derived from the liver, and each of those lipa proteins has won, and only one apple like a protein b one hundred. On IT, we shortened IT and just call A A bo b because we don't really worry about a liba protein b forty eight, which is a sd attached to kyo micronesia, responsible for fat absorption in the gut. They're very short lived.

They don't really factor into a throws grosses. So are going to just for the purse out there. There's an apo b forty eight when I going to talk about IT.

So when I say apple b, when i'm talking about is a protein that wraps around a subset of these lipper proteins, there's another family of apple proteins called apple a or apple like a protein a. This is a much more complicated family. And I am going to talk about IT.

Here is where we would take an hour to just explain how the April paper protein a family works. But i'll I give the punch line is. There were many apple lipper protein is is variable numbers of apple aes on those proteins.

And they are all part of a family called high density liapis proteins back to the apo b guys. They are of the low density like a protein linyard. So you've heard the term L D in hdl.

What is the referring to? It's basically referring to the relative concentrations of protein and lipids in the lipper proteins, and not surprisingly, based on their names, that hdl are higher density, more protein, less lipid, L, D S, low density labor proteins, and V L D S, very low density labor proteins and ideals. Intermediate density of proteins are all lower density, which means more lip to protein.

There are different sizes. There's a little bunch other things going on. Most important fact in all of this is that the APP o bees are athletic ic. So what we're about to talk about is perpetuated by labor proteins that have an abb on them. So everything in the story right now is just about how do you get clustering around .

the body and these proteins that have lipid in the middle. So let's just take A B for example. Many, many billions of them flooding round in our body, even in the health est of people, and they're being shuttle to tissues that need them, likely a jin's muscle heart at sea.

What sets the demand for these things so far? Incident, could somebody have relatively high L, D, L, maybe even even higher than highland of chart, or even above highland apple b, but there's some sort of demand, metal olic demand or or the the wait training a lot, or they are running marathon's. And so they need a lot of L D O.

The reason I ask is because it's so easy for the uninformed person, which I include myself in that group, to just look here. O L D O bad, collector bad, A O B bad when in fact um you very graciously spelled out the fact that they these things actually perform A A functional role in the healthy body. So before we get into why they are or can be bad, why would you want a low density like for protein? What is that doing for somebody? And is there um any circumstance where the way people are exercising or thinking or not sleeping or sleeping too much, is that a higher level actually reflects at a healthy metabolic?

We don't have any evidence of that today. All of the functions that I described can be function can be done by the H D. L. So the high dency labor proteins, the apple A S, can do all of IT.

So apple b and low dency labor proteins are just um they're just the necessary we don't a way .

now we don't understand why we have a matter. This is the part that's really interesting to me. Most species do not even have abb.

And as a result .

of that, most species are chemically incapable of arthritic k rosas.

So if someone could zero out their A, O, B and their L, D, we assume they would function just fine.

We know they would because we have certain people who walk around the genetic mutations that render them that way.

Wa.

furthermore, we also know that there's a bit of a myth out there that clutter all the customer you measure in your blood is essential for brain health, for example. It's an understandable thing, right? You can speak to this very eloquently the .

role of clusters in the brain when I was a postdoc at stanford um so I was point out I was more than stanford trained .

and stanford works stanford so that like you can die there .

there are exactly we cared already um the when I was a post dog, I worked with the gun benbrook. U I know you know probably um as a different person then for reasons that people can look at ben's name. Um anyway incredible scientist.

And but there was someone in his lab that discovered that cholesterol is a critical component of the synaptic genesis process, the the formation of connections between neurons and the developing brain. And then they went went on to lead to the discovery of things like throw respondents being important for syn napi jana. It's about collection al central in the brain development mechanism. You want collection al around for brain development. In fact, I think very low fat diets and very low cluster's diet during early development can really impaired brain development.

As I understand. It's entirely clear why. But here's what we know. When you're born, your serum cluster al levels are very low. So children, infants and children have very low levels of cause they would have. And I should explain one thing .

that's important inside, right? I think there there, sorry, interact by milland, of course, the sheep around of iron neural axons, which accelerated proportion of nerve signals in which is deficient in things like multiple scaroons, is is essentially fat made up of first Philippine and requires clutter, offer synthetic. But but Young children are not very well milani. I mean.

this final court is my money. This is what interesting, right? We would all agree that clue is more important to children into anybody else, right? IT would be the most important substrate for C. N. S. development.

And yet infants and children have virtually unmeasurable levels of classical IT really starts to take off in your teenage years, right? So cluster basically serum cluster al levels rise basically monotonic ally throughout life. Um women get a big bump at mana pause, so IT really goes up for them.

Um but what's interesting is how is IT? How do we reconcile the fact that infants and children have really low levels of serum cluster'd, yet clearly undergo cns maturation without any problems? And IT basically comes out of the following. What you measure in the serum is but a fraction of the total body pool of cholesterol.

So we get a little bit of a, the light under the, you know, the what the the the the the street lamp under the drunk under the different because we're looking there, we tend to think that that's what we're seeing. But um if you took the entire circulatory ory pool of cholesterol, it's about ten percent of your total body. Cholesterol is a tiny fraction of IT.

It's what we measure because that's what we have access to. But I really represents virtually none of IT. Um I do want to say something because you mentioned L D L.

I want to tie this back to the reader, the listener rather um A O B refers to the light of protein, the singular light of protein wrapped around an L D L particle. So if you happen to be lucky enough that your doctor measures in A O B level, it's a blood test. IT says A O B X number of milligrams per decelea, or that's measuring the concentration of that protein.

IT is a direct measurement of the concentration of L D L and V L D L particles. When you have a blood test that says L D L, IT usually doesn't say L D L. IT usually says L D L C or L D L cholesterol, because L D L is not measurement.

L D L cholesterol is a laboratory measurement, and it's just taking the total number of L D L particles, breaking them apart and measuring how much cholesterol is in them. So L D L, C measures the total concentration of classes in the lds. A O B measures the number of them, and they're different.

But one of them is far superior at predicting risk. In its A O B. The number of particles is much more predictive of risk than the amount of collection ol contained within them.

fascinating. First time i've understood A G L L D L and these library proteins in a way that makes sense. So thank you. sure. Others feel the same way. What apple b level is your red flag cut off, right? And SHE had my baby measured recently and i'm definitely above .

the high end be discussing over dinner .

and and just to tie this back um I hope that's a stake dinner and that should be fine given the fact that dietary cholesterol has no direct link to A O B.

And but dieter, saturated fat does .

okay so but which .

is not say where .

mistake well but I not a certainly one of the fatal cuts, although probably will be for me um so what's what's the high end that you a higher flag at what point you start say we need to do something and they will talk about what people can do?

Ah so this is a complicated question because IT depends on so many factors. The first factor IT depends on is what is your objective? And I do post this question directly to a patient, right? So I say, look, we've got this disease, that's the number one cause of death.

Now you can die with IT or you can die from IT. That those your choices, statistically speaking, more people will die from IT than anything else. But if you live long enough, we will all die to some extent.

So if you're me and I come from a family history, as you know, I write about this in the book where basically every man and my family accept one has died of athletes, groceries, and they have all done so very premature. Ly, my dad's lost brothers in their forties and fifties um by some miracle my dad is still alive at eighty six. But I think that's in large part because he at least had the good sense to listen to doctors and take medication to lower his clustering blood pressure.

Um if your objective is to not die from heart disease and only to die with IT, then you want APP b as low as possible. Now how low you go depends on when you start, because one way to think about this is its an area under the curve problem. The longer you wait to start doing something about this, the more aggressively you need to do something about IT.

Um I think I Better way to think about this though, is to go back to what we talked about with smoking. So would you agree that smoking is cauSally related to lon cancer? yes. So just to be clear, and do you do not think that it's just an association that smokers get more lung cancer?

No, I do not.

You you know if you believe that smoking causes lung cancer, then yes.

OK. I mean, there are a number of mechanistic steps in in between. I mean, somebody was really wanted get uh to your drill into the logic. They could say, okay, not actually smoking at a you know some disruption .

of the the the the very believed here yeah, i'm so but but i'm going in some place very important here, because if there's one topic that doesn't get enough attention in medicine is causality. And casuality is an obsession of mine. Like most of the day on summer level, I sit around thinking about cassity.

And I think the hardest part about studying medicine with respective to human beings is how difficult IT is to infer causality for most things that we do. So if you believe that smoking is cauSally related to lan cancer, then smoking sensation reduces the probability of lan cancer. That is, that is a logical equivalency.

There can be no debate about that. What if I said to you and you this is going to be our new philosophy around smoking assault. You're going to annoy you desire of smoking sensation. So um if people pick up smoking, no problem.

We're in won to smoke, but we're going to assess the risk for lung cancer using a model that predicts when the ten year risk of lung cancer gets above a certain level, we're gona recommend that they stop smoking. So we're going to look at their age, their sex, their family history, some biomarkers that might help us. We're going to even do scans of their lungs.

And once we think they cross a thresh hold where the risk of lung cancer is high enough, let's just say it's twenty five percent boom. You make them stop. You tell them, is time to stop.

Is that a logical approach to treating smoking in lang cancer? Or would be Better to say, given that we know cigarettes are causing ly related to this, how about you never start smoking in the minute you do, we pull the cigarette out of your mouth and explained you that you're doing something IT is cauSally related. Of course, I would be the latter, not the former.

IT would be idiotic to suggest that we endorse smoking until you cross a certain threshold. Well, this now becomes the german question. There is no ambiguity that A O B is cauSally related to author sa rosa.

You know how? How can I tell you that? I can tell you that looking at all of the clinical trial literature, all of the epidemic fidem ological literature, and perhaps even most importantly, the mendelian ananias, all of these things tell us do, because by madelin random zo.

meaning genetic mutation, humans out there that make very .

little a or access. So you can say.

if you make very little, you aren't gonna die as a quickly in your life, as if you make too much.

That's so medal ization is such an elegant tool where you basically LED genes do the round ization. And as you said, there is a gradation of L D, L concentration, b concentration that occurs from insanely low to insanely high. And this is a wildly polygenic, Polly.

More fix set of conditions. And we can look at the outcomes of those people based on the random sorting of those genes. And there's no ambiguity.

L, D, L is cauSally related. L, the oca. O, B cauSally related to athletes. Gross, well, if that's true, and I haven't seen a credible argument that is not, there are people who argue that, that is not, by the way, but they just don't have credibility in their arguments, then you have to say that what we're doing in medicine today is very backwards because what we're doing in medicine today is the following.

We're saying i'm coming out this in a long way, but your question is so important that I want to answer this way. Were answering your question today as follows. We're saying and lets do a ten year risk calculation of your risk of mace make sense for major adverse cardiac event.

IT is the metric we use in medicine. So a major adverse cardio event is a heart attack, stroke, you or death, basically resulting from these things. So and we have calculators that are pretty good at predicting your ten year event risk. They'll look at your cholesterol levels, your blood pressure, i'll ask if you smoke, they'll ask some family history questions.

They'll spit out a number now we should do years after the fact um and I don't know if we did IT for a person who is you know you're in your mid forties, like I would probably spit out less than five percent with for a major adverse cardiac event in the next ten years. In fact, the models don't even work if age is below forty. So the first time I went to do one of these tests when I was in my mid thirties, I couldn't do IT like the the algorithm breaks that sort like, you know, just doesn't work.

So the the implication there is if you're, uh if your mace risk is less than five percent, the thinking is you do not need to treat L L abb. I argue that that makes absolutely no sense. It's just as idiotic as the analogy I used around smoking.

If a risk is caught and IT is modifiable, IT should be modified regardless of the risk tae in duration. So then the question becomes to what level? And again, the earlier you start, the less aggressive you need to be, the less damage that they're already.

So for example, we do city angie ms, on our patients. If the city anagram shows no evidence of classification, no evidence of soft, that means grossly, the corner arteries are still Normal. history.

Logically, they're probably not, because nobody probably makes IT to our age with history logically perfect coral arteries. You know, we might be satisfied with a person's A O B being at the fifth percent, all of the population, which would be about sixty milligrams predecessor. But if we have any other factors, meaning we're starting later in life, you or a person already has gross evidence of disease qualification, soft black family history is significant. Any other risk factors are present. I mean will will treat A O B to thirty to forty milligrams per desolator, which is you know probably the first percent time.

And if somebody sitting up in there a low one thirties, um where does that what kind of flag does that raise for you? And I realized it's highly contextual.

A H no, it's a huge and flag again. Um just because something is causal doesn't mean it's you. You're guaranteed to get IT.

There are smokers who don't get lung cancer. So now there's going to be somebody listening to this who says, my grandmothers, ninety five years old, she's her. Her class is sky high and she's alive and well. And I will say, absolutely, there are a lot of people walking around that way, just as there are a lot of smokers walking around who don't yet lung cancer. Um you you can't you can't compute these things on an individual basis.

You basically have to ask the question um how do I make the best judgment about an individual from had a regeneration population data and based on what causes and non caul inferences around risk? So you know to me, if a person has very high above and they do not want to be treated for IT, then the best we would do is say, let's at least establish that there are no other risk factors present, and let's at least do the most investigation we can around the existing damage. And if that person has a perfect city geo gram, i'm going to push less hard than if they have a devastating and geography, by the way, devastating in my is just any amount of classification or soft black. Anything that shows up grossly that you can see on A C T. Skin means that you've got a decade plus of really bad histology .

building up to IT. This issue casuality, I think, now becomes very clear ious. Why that is so crucial and um really appreciate the way you spell that out.

So let's say somebody y's apple b is you know eighty one hundred, let's say one hundred and thirty, for example, what sorts of things can they do to reduce that number is is always going to be prescription medication. And if so, what are the more common forms of prescription medication that work best? What their side of effect profiles so on.

So yeah usually once you want to start getting down into the thirty to sixty range, you're gonna require pharmacotherapy. Um but you know usually we want to see how far we can get with nutrition. So fixing insulin resistance in an instant resistance person will will bring this down, right?

So one of the hallMarks of instant resistance is elevated triglycerides. They haven't we have to talk about triglycerides, but they they weren't some attention because I mentioned that earlier. But one of the other things that the light of proteins Carry is triggering ze.

So you're Carrying fat and cholesterol. And if you recall, A O, B represents the number of particles. So the purpose of them is to be Carrying around mostly close all.

But if you have a high amount of triglyceride, you're basically using up cargo space on the ships. And so you need more ships. So if a person has elevated triglyphs, I consider anything over one hundred to be elevated.

Even the most laboratory tests would consider Normal to be up to one hundred and fifty on the gram's pretest year. Um we would want to fix their insulin resistance, bring the tricks, wait down. I I wouldn't to see trade no more than two times. The H D L cholesterol, or three l class is, you know sixty milligrams per decelea, or I consider one twenty to be through the roof high. And ideally we want tricks at or below H D L.

Does that mean data fat?

No, actually it's most easily accomplished through carbon hydrate restriction. Yeah, carbon hydrate triggers rides in some ways are kind of an integral of carbonate consumption um any energy restriction will get IT for you um but it's most sensitive to um to restriction of of even even under echo li c conditions, carbon hydrate restriction will lower trackless rates so again, energy restriction would be kind of first order of business um but within that cover hype brid d restrictions will probably get you there quicker so know you want to take the the low hanging fruit off the table.

And where does exercise play role?

Minimal role for .

improving .

in social sensitive? No, no, i'm sorry for improving .

lives in general .

yeah but they .

can improve special combinations of simple so once that comes .

down to farmer of therapy, um you basically have several classes of drugs. So the most obvious in the one that most people are wherever called state, so status work both directly and indirectly on the problem. So directly they work by targeting and um very high in the synthetic pathway of cholesterol production um and I was called H M G coa reduct.

And I think it's the second committed step. Might I could be wrong on that is I don't think it's the first committed step, but you that that enzi m gets targeted kind of ubiquity, sly throughout the body. And in response to that, the liver senses a reduction in the body's pool of class sterol.

And the liver really tries to regulate this. So the liver, in response to that, increases its expression of L D L receptors. So the liver itself has ldl receptors on its surface.

And as the bodies pool of clustered al goes down, the liver senses this reduction and says, I want to bring more cluster's in, more l dio. Receptors go up and more A, O, B particles are coming out of circulation. So that's really the dominant way that they work.

And in fact, that's kind of a dominant way that all of these drugs work. So another class of drug is called eea ib. IT works by blocking.

We can get as technical as you want on this. It's called the name and pixi one like one transporter in the entire site. Um I like to explain this. I borrow this explanation from time, day, spring, but the entire site is obviously the luminous gut side cell. That is responsible for absorption of cluster's.

Remember I said earlier, most the clue you eat, you don't absorb the reason you can't absorb IT is an as terrified classroom molecule cannot come in the neon pixi one like one transport. It's it's physically too large, but the clusters that you synthesize, which once IT makes its way back to the liver, gets secreted in bio down the and teston that is unterrified and readily fits into that transport. So I kind of describe that guy as the ticket taker at the bar.

He lets everybody in, as long as they fit through the door. There's a checkpoint inside the bar that basically says, do we have too much cholesterol? If so, spit IT out.

And there's another door that act more like the bouncer. And he's called the atp binding his head. G five, g eight.

And he spits access cluster all out. And if that systems working fine, everything is great. But in a lot of people, that ATP buying is that doesn't work very well. And IT can't properly regulate the total body pool of clustering. So there's a drug called ezetimibe that simply blocks the ticket taker.

Are there side effects to state? And as ati is, atmic has .

virtually no side effects. It's you can think of IT as a drug that's acting outside the body, right? It's sort of acting on you know a turn style door in your gut um I have seen one patient yet uh sort of loose stools from IT that became enough the issue that we discontinued IT.

Um I would say that when eea ab is combined with a status which is very commonly done um it's not unheard of. I don't I can't give you a number, but IT could be as high as ten percent that you see an elevation in transplant es, which are enzymes that are made by the liver in response to some irritation. So so this is where I think it's unclear what the clinical significance of that is.

We tend to abort the strategy in the presence of elevated transactions. Um even though the literature says you don't need to, our view is we have other options. Why would we tolerate any inflation tion if you don't need to? Stands do have side effects.

So five percent of people, genuinely and legitimately, gatiss AI get a muscle sourness they can be debilitating ating. They can feel like kind of the worst work out you've ever had that you know, like the day after you've like, imagine you hadn't lifted weights in six months. And then you you came over and I made you do the most brutal workout of your life.

You know, you would feel, well, I work out often, but every time I come over to your house, you put me through the most part of work out i've ever been through. I think you and campaigns are the two people, then you put me through workouts that get me sore for at least, uh, two weeks after each visit.

So so that so is that imagine you would have that persisting, that five percent of people get that response from a status. And obviously, that's just none. You know it's not it's an not do um there's a narrower subset of people that um do do do get brain fog and do experience brain frog from stands.

And when we don't really understand the why there we have some theories as to why you know maybe there maybe they're getting too much of a reduction in central. This is um again, it's a subjective finding, but given that we have so many tools in the tool kit, like we don't have to tolerate side effects with these drugs anymore. There is a day when you know you had somebody who just had a heart attack and they're basically looking down the barrel of being on a status for the rest of their life.

And they were like two of them and they you know had tons of side effects. And we didn't matter today. While there were probably nine statenland out there, there were really only four that we even use and at least two of them have such a low side effect profile are not as post.

But if I mean pots, a bit of the potent is the wrong word. They don't have the same effect um but they're very potent because you at least one of them, you're taken at such a low dose um that we've got lots of state options. The third side, effective status, which again not common but can be ignored, is instant resistance.

So IT really, this is one of I think one of the benefits of at least having periodic gm tracking is we'll see, you know, we have a patient who happened to be wearing C. G. M. In general, and then we started him on ten milligrams of brazos, a statton, which is probably the work course start right now.

It's a it's a generic number for crustal um and he pings this like a couple of weeks later, he like, man, my glue cose is like ten points up consistently from where IT has Normally been kind of human don hot. We'd probably shooted a few things after two months like let's just stop the cross store and uh see if that fixes IT and IT immediately fixed IT. So there you know we reintroduced the questore and IT happened again.

So there is no doubt my mind that you no doubt in my mind that crestor was responsible for that. Um and again, you could say, well, maybe that's not that clinically significant, but I would argue, why bother? I have other choices.

So those are your two big ones um the next one that is really the big one or R P C S K nine inhibits. So you know um gosh, coming up about twenty years ago, maybe a woman named Helen hobs are made a discovery of a group of people that had disease called familiar hyper clue stroma. So F H or familiar hyper clusterin a is a very genetic heterogeneous condition.

Going back to that mendelian ananias ation study, these are the people on the far end that show us how high lipid levels cause athrob k rosas. So these people have very high clustering levels, typically north of three hundred milligrams per decel leader, their l dio cluster alone is, by definition, at least one hundred ninety milligrams per desolator. A very high incidents of athrob sis in these people, along with other sort of injuries like they are, have so much questions they accumulated in their tendance, in their eyes of it's, it's, it's really devastating condition, if not managed correctly.

And he discovered this mutation in A A gene for pcs canine that codes for a protein that degrades l dio receptors. So these people had hyper functioning P C S K I genes. So their genes were just chopping down all the audio receptors in the liver.

So these people weren't clearing L D L. But five years later, another subset of the population were discovered that we're the exact opposite. These people had hypo functioning P C S K I.

They had virtually unmeasurable. These people had l ocala tra. Levels of ten to twenty milligan, ms. Predecessors or and not surprisingly, they have no heart disease, so that LED to the development of a couple of amazing drugs that are now used.

So I take one of these drugs i've been taking one of these drugs for, and I pretend in twenty and fifteen. So it's an injectable drug. I take IT every two weeks, and it's a called A P C S K. Nine inhibited. So the drug blocks the protein and therefore gives me more L D L receptors, yanks, more apple Beata circulation.

Interesting, when we were talking about side effects, I um I was thinking, are there any short term benefits away because we call this positive side effects. But let's think of IT more directly in line with the underline biology. Let's say my apple b is high, mid range to high.

You know what say one hundred you know eighty to one hundred um and I improve my insulin resistance through nutrition, but we decided, you know he doesn't go down so much. So we're going to continue to to try and knock this number down and and I take any number of different drugs to reduce IT. Do I immediately start to feel Better now? So there's no okay.

And and I think that's an important, important point because of the causality issue that we're talking about earlier because a lot of people are working around out there feeling fine. Their apple b might be a bit high that either know IT or don't know IT, but they think i'm feeling fine. And you gave a very rational argument earlier as to why because of the casuality involved, IT makes far more sense to intervene .

yeah we don't want to rely on feeling when IT comes to athletes are is just to put some perspective on this. When I was in medical school, we had I I think I even write about this in the book. We had a pathology lecture where the professor stands up there, and he says, what is the most common presentation of a heart attack? And you know, as keener first year made students, hands shoots straight up.

Chest pain? No, that's not the most common. Uh, uh, uh, shoulder pain aren't radiating and done. The left, no, nadia, no short of breath. We rattled this off for a few minutes and goes death. The single most common presentation for a mile cardio in function is death more enough I would say today, I was twenty five years ago today, it's probably not the most common because um advance cardiac life support is so much Better, but it's still strikingly common. So what you can say that .

um the best predict of a heart attack is still a heart attack. Well, I mean, not saying that the best underlying prediction but and I actually this at home when I was a post dog I was living in service is going never forget this taking my coffee in uh out on my porch in the morning.

This is right near the usf parnasse campus and this guy is walking on the street is right about my age and I said hello and he said hello he walked a few more steps in, boom. He just hit the concrete and died right in front of me. He took of a mineral de know that he was truly dead. I'll never forget IT because it's A G it's it's an event, right? And and I followed up on this and because his family, the whole thing, because they want to report, and no cocaine in the system, no prior history of any kind of health issues, but he was just strolling along and his bomb as if he'd been hit by a boss.

yes. So it's I mean, again, this is just one of those things where we're we're been a lot of time talking about things that feel good and feel bad when you change them, right, like you take a person who's not sleeping well but who thinks they're sleeping well and you ask them for a leap of faith, which is, hey, give me a month to help you sleep really well yeah, you're gonna feel Better.

You might not know IT now because you don't know how bad is sleeping now. You've become acclimated to this. But this is not one of those damages.

You know, exercise, nutrition, sleep, all those things. When you do those things Better, you feel Better. But no, I don't want to over promise on this. You're not going to feel Better in the moment when you fix your lipids, but you'll feel Better when you don't have a heart attack.

So by all this logic, everybody should get their apple be measured. How early and lifetime people do that, starting in there twent, uh.

in their third ties. Certainly, if you have a family history that is of any concern like and reach like, if I could live my life over again, knowing if I knew everything and then that I know today, yeah, I would have had mine measured in my twins know I did. I didn't get my A O B measured for the first time, probably till I was in my forties because you that's well, yeah maybe late thirties, early forties, right? Um I had my first calcium scan when I was thirty five and I had the bag borrow, steal to get IT done because everyone was like, why is a thirty five world going to do this but I I just felt something was wrong given my family history um and i'm gd. I did i'm glad I did that because I learned something that that completely change the direction of my life.

Okay, I know my be numbers and I might be that guy who's up in the you know above one hundred so I am going to get this treated. That's a promise to myself. We covered um the three major risk factors which were blood pressure um keeping that in check, don't smoke um and abb. And we've now talked about the things to adjust A O B levels. We did not really talk about things to adjust blood pressure and assuming exercise says .

one of the former ae management is a huge one here. So know you take a person who's blood and and this is one of those things where we don't immediately jump on the pharmacotherapy train with blood pressure because here there are side effects sometimes um and you do have to worry about over shooting. You don't really have to worry about overshooting a person's lip adds.

We do back off if we overshoot, but IT doesn't cause a symptom. There's not there's not a short term immediate risk from doing that. If you overshoot somebody's blood pressure medication, you trade one problem for another problem.

They become light headed. When they get up to p at night, they fall in buying their head. That's a devastating consequence, totally unacceptable.

So our goal is to see how much we can lower blood pressure without medication before return to medication. And let's be clear, the meds today are so much Better than they used to be. Again, there was a day when the side effects of these medicines were miserable.

That's that's simply not the case today. I mean asia habitus Angel tencent receptor blockers. I mean these things are very well tolerated, especially the arbs. Um so again, almost anybody can be on these things.

But if we could get a person to lose ten pounds and exercise every day, we see great effects with zone to stuff, right? So kind of the low intensity cardio. What's your .

recommendation there? I know you talk about this in the book, but we i've thrown out numbers about one hundred and fifty, two hundred eighty months per week. You go a bit higher yeah .

we go one eighty to two, fifty to forty yeah I like to see three to four hours a week of zone two um so that's an important piece and sleep is an important piece um so get the sleep right, get the exercise right. If if you're if you're over nourished, let's correct that problem and if all of that doesn't work and by the way, that works a lot of the time now at work, most of the time. If that doesn't work, then we've got pharma therapy.

There is still a true phenomenon of essential hypertension, which is in individuals. For him, all the fixed ble stuff has been fixed, and they still have high blood pressure. We still have to medicate those folks, by the way, to something that I want to mention here that doesn't get much attention, but it's so important, which is the effective high blood pressure on the kidney and also the brain itself.

We talk about the brain, we've talked about the heart, but the kidney doesn't get enough attention. The kidney is a remarkable organ. And I think if you're really in this game of trying to live longer, right, if you if you think, hey, you know, maybe we'll live eighty, eighty five years.

But if we kind of start doing all of these other things and really optimizing our behaviors, that could be ninety five. Well, you have to start thinking about the capacity, the kidney and once the geri's filtration rate falls below a certain level um you have to be very careful with how you live your life. And unfortunately, this is one of those things that is another sort of mistake that made in kind of modern medicine, which is we don't pay enough attention to how to measure kidding function correctly.

We rely very heavily on something called um creatinine as supposed to look at another biomarker called system and ca, which is far more accurate. And we also tolerate too low of a kidney function for a person's age. So we look at you know we might look at someone whose fifty whose kidney function is at sixty five per cent and say you're totally fine because it's true that at sixty five percent there is no problem.

But you're not thinking, well, if this person's to live in another forty years and this continues to go down, they're going to potentially be staring on the barrel of needing dialysis the last five years of their life. Again, you don't want you want to die with compromise kidney function, but never from compromise kidney function. In fact, a hazard ratio of all cosmetically associated with compromise kd function is even greater than that of heart disease.

Once, once you cross that threshold, I mean lights out, once you are needing dialysis, I mean your risk of death is higher than that of someone with high blood pressure, smoking, even someone who has cancer. You have a higher risk of death having n stage raining disease, then you do have a cancer. So um the kidney is so sensitive to blood pressure. This is a tiny organ that on every pump p of your heart is getting twenty to twenty five percent of your blood oh so just imagine how sensitive and suspect IT is to .

elevated blood pressure. We've covered quite a few corners of avoiding the major killer are the claros is um let's talk about cancer. Nobody wants cancer.

Everybody seems to know somebody who has had or died of cancer and probably no surprise given that it's number two on the list. What are the numbers and what can people do to offset cancer? Um and of course can't.

There are huge number of different types of cancer. And inside of this conversation I just wanted um remark that might be good to have a conversation about alcohol, which we didn't talk about in the the last last discussion. But if alcohol is involved or is a risk factor rather for a quarter of vascular disease or three proof vascular disease, now would probably be the time to to mention .

IT yeah um this has been looked at in a number of ways um and um you know so if you if you look at sort of top line epidemiology and you've you've heard of these things called the french paradox, which is our common like they eat all the fatty stuff and drink all this wine and they have a slit lower risk of cardio asked disease.

You have kind of throw that stuff out the window because there are so many confounders there that is kind of useless epidemiology. If you really look at the data clearly, and there is actually a really eligant analysis that included some genetic studies that came out of jammu about a year ago, it's actually pretty clear that there is no dose of Ethanol ol that is healthy. okay.

So there's no j curve. So IT used to there used to be kind of this literature that said there's A J curve associated with Ethanol. So meaning um at at total abstinence, there's a slightly higher risk of death.

Then if you're drinking one drink a day and then if you go beyond one drink a day, the the rate of death starts to climb. The problem with that analysis. So there's just been a lot of conservation around that. But the problem with those analysis are multiple, but the most important of these are that the abstainers have a reason for abstaining typically, and those reasons can be extracted statistically from these analyses. So i'll leave IT at that without I an have written many blog posts about this if people are really interested um they can they can go and talk about that. I also do talk about this a little bit in the book by the way um but the the short answer is there is no dose of Ethanol that is health thy I would argue that it's not a straight line of risk. But IT probably goes, I think from zero to one, there's probably no measure harm for most people.

one per day or one per week.

probably one per day up to one per day. It's probably very difficult to discern the harm. But i'm going to put a cavy out on that, that i'll come back to.

And then I think the risk starts to climb pretty deeply after that. And I think he climbs non linearly after that. That that is my reading of the literature. okay. So then how do you decide if you're going to have up to one drink a day? And by where that's not the same as seven a week because that doesn't mean seven in a day.

right? Which we know is is really deterrment tal, right, especially for the brain, right, but also the cades that result from disrupted sleep, not just for that one night, but multiple nights. Yeah, the literature i've seen on alcohol, you know that the most now you again, this is an emerging literature because what you're describing is exactly right that people are now some more conservative folks are starting to place at at two drinks per week total beyond which you start running in the issues, especially for women, in terms of breast cancer risk, which is only made .

weekend can circle you. My view is if you can not drink at all, you're Better off not drinking at all and people always say to me, well, Peter, what's your view on this and my view is I do drink um i'll go weeks at a time without having a drink. I haven't had a drink you know I had one drink since I saw you last a couple weeks ago because i've been sick of thinking, well gosh, like the decade stack against me right now.

Why would I do anything to stack and more um but my philosophy which is half tongue in cheek but is is true is like I just don't drink bad alcohol. You know, I I sort of my wife saw me to this other day, we open up a bottle line and IT was a very expensive bottle line. I took a sip and was like, yeah, I just dumped my glass was like, I don't know, just doesn't taste right to me and IT tastes fine to her so I don't think IT was that the wine and spoil IT was just I didn't like the taste of IT enough to justify drinking IT like I don't feel drinking .

IT yeah I fortunately that there were times in life, yeah, certainly college and porportions graduate school I do. But i've never really enjoyed the the taste experience of alcohol. So I only alcoa, the plane could disapearance would even notice.

But i'll have one everyones in a while of of that mindset. Great to hear that zero is Better than any because I think everyone agrees on that. So IT doesn't appear that alcohol can be directly linked to a car to accused disease.

And three of vascular to sleep on cardiovascular section is profound, and I do think that the impact of Ethanol on sleep is under appreciated.

You and here, I think we should do IT not to matt Walker, the great matt Walker, because, you know, ten years ago, if we someone had a conversation about sleep and how critical IT is, and how not getting enough quality sleep is dangerous, sever, people have just kind of shake their heads and say, what's the evidence for that I think that really um most of the credit for alerting people to these issues around not getting enough sleep, it's just remarkable what happened in the last decade thanks to matt.

And in what on that topic, we we have the other next horse seen of death, the nearly general diseases. I think those are also heavily impacted, especially on the dimension de by Ethanol. So again, I want to be careful when I say this stuff, right? I don't believe in fear mongering, okay, I I you know I just said a moment, all say again, I I drink k cocoa and and and you do drink k alcohol.

But I think that one has to make the tradeoffs, which is like if I really do love the taste of certain spanish lines, I really do love the taste of certain to killers, certain messages, and I really do love the taste of certain weird, esoteric belgian beers. And IT really does give me pleasure to consume those things in the same way that gives me pleasure to concern certain foods that are quite rapid, right? You know, there's no upside in consuming a Brownie that my kid just made, except the fact my kid just made IT.

And it's fun to eat the round with them, right? So, you know, we come back to this thing about, like longevity is also about health span. And part of health span is quality of life. And you know, I write about this in the book that I I think there is a day when my approach to this was purely an engineering approach, which was we are going to optimize every molecule of my being for this.

And if you, if you if you go so far on that rabbit hole that the quality of your life deteriorates, what's the point? So that's why I think for somebody like you who says, like you could take all the alcohol to this so I wouldn't even notice, then it's a great reason not to bother drinking. I wouldn't put myself at the opposite of that spectrum, but i'm probably further to the spectrum you know where yeah if you told me I could never drink alcohol again, I would be fine with IT, but i'd be giving something up that I enjoy um but at the same time I know if I have two drinks with dinner my sleep sucks and therefore that's that's just a threshold I rarely, rarely cross I .

certainly have my vices. Alcohol just doesn't happen to be one of them. What about cancer? Again, nobody wants cancer. We've all known people have died of cancer or head cancer. What can be done to reduce one's the risk of cancer?

Well, you asked earlier about the numbers. Let's throws the numbers out there, right? So globally, we're talking about eleven, twelve million deaths per year, about half the number of a vd, still a staggering number um at the individual level, put at this way somewhere between one and three and one in four chance anyone listening to this or watching us going to a cancer in their lifetime.

But what's the probably they will die from that, that about .

one in six chance of die? okay.

So is IT true that every male ts prostate cancer, in other words, and found every man .

will die with prostate cancer and some will die from IT. You and I have prostate cancer right now.

Thank you for informing here.

Hopefully we will not die IT. We should not die of the prostate cancer. Colon cancer are cancers that no one should ever die from because they're so easy to screen for, they're so easy to treat when they are in their infancy. Um that is totally unacceptable that people are dying from this.

There are other cancers for which I can't really say that breast cancer much more complicated pancrates a cancer much more complicated clear best to my multiformity much more complicated so that you know, as you said a second ago, cancer is not a disease. IT is a category of diseases. Each is not just that each organ is different and breathe difference from pancreatic. It's that with breast cancer E R P R positive, her two new positive is a totally different disease from the triple negative breast cancers.

those with brack commutations or non bra commutation.

So even putting that aside, just looking at the the hormonal profile of the individual breast cancers, they're totally different diseases. So it's not just that breast cancer different from prostate cancer is that all breast cancers are quite different.

Maybe I should frame the question will differently then, given the vast number of different types of cancers in categories.

your question is still affair when I just want to throw that cavy out out there. So now to your question OK, so what do we know? IT turns out that we can very comfortably speak to um several things.

One is the role that genes play. So um maybe i'll just spend one second on a gene. One of one thing for for the for the viewer, we want a difference between what are called german mutations and semantic mutations. So um your germline and my germline are set when we were born. Our germline mutations uh any mutations we have in german genes are inherit from our parents.

So I got .

those things. So question one is how much of cancer results from those types of genetic mutations? And the answer is very little less than five percent.

So very, you mention when a moment I O O brack a. Okay, so, so mutations in bracket are germ line mutations. A woman will get a black mutation from one of her parents.

And we will often have a sense of that just from the family history. You know, when mom and sister and and and grandmother had breast cancer, you've got a breast cancer gene. Now IT might be bracket.

IT might be another gene that's not bracket, but there's no ambiguity. And we test for these genes mostly just for insurance purposes, Frankly, but there's no ambiguity that that was a germ line transmission of a gene that is arriving cancer. But ninety five plus percent of cancers are not arising from german mutations.

They are rising from semantic mutations or acquired mutations. So the question then becomes, what is driving thematic mutation? And the two clearest indications of drivers of smart mutation are smoking and obesity. Smoking, we've talked about, let's put that aside for a moment.

I'm so surprised about obesity. I don't know why i'm surprized, but I never heard this. I'm probably just .

naive to the literature. yeah. So obesity is now the second most prevalent environmental driver of cancer.

Now I will argue and I think I argue this in the book, hopefully pretty convincing. I don't think it's obesity per say. I think obesity is just a macerating proxy.

And what is obesity? Obesity simply is defined, my body mass index. Well, first of all, ah I don't think I am obese, but i'm i'm way overweight on B M. I. You probably are to so let's just clinically .

diagnosed able as a obese are you? Oh no. Well, not well.

clinically.

Ba proba twenty seven .

or twenty eight.

Okay, it's been in a while since I i've checked. I can I only know about that percenters and things like that.

So so basically, like B, M, I is a far from perfect proxy. But at the population level, it's what we use. I wish we would get off. And by the way, I think it's really .

crap because IT doesn't take into account lean verses.

Yeah I I think we could get Better data if we looked at waste to high ratio. That's a way Better metric. So this is just a quick test for everybody.

It's I, I. I'm going to argue your B, M, I is less relevant to me than your eye color. But if your waste circumference is more than fifty percent of your height, you should be concerned.

okay. Well then, okay, yeah, you're fired by that trip, right? That's important. So if you're six feet tall, your waste Better be under thirty six inches.

And if it's over, I would argue that the definition of obesity, not your B M. I being over thirty. So um back to this issue because we're using such a crude measurement, IT basically is catching a whole bunch of stuff.

But the question is what's driving IT? I think if you really look at the physiology of cancer, I don't think it's obesity. I think it's two things that come with obesity.

Insulin resistance, which is you know two thirds to three quarters of obese individuals, or insulin resistance and inflation tion. And I think those two things with the inflation tion in the immune dis function, with the infant resistance hyper basically tonic growth stimulus that's coming. That's what's driving cancer.

So again, is IT because a person is storing extra fat, you know and their love handles that that's driving the risk of cancer. No, that's those are just two things that are coming on for the ride. So beyond those two things and all along with they're also certain environmental toxins, we absolutely know we're doing this right.

So we understand that people who you know have exposure to best have a much higher risk, certain type of long cancers and things like for the part, those are big risks. Beyond that, we talk about alcohol in certain cases, absolutely. Alcohol is a current um it's the dose part still isn't clear to me, I don't know is one drink a day moving the needle much on cancer risk, percy, it's not clear and .

IT might depend on those genetic rediscovery .

tion yes so so yeah if step one is don't get cancer, you have no control over your genes. You have control over smoking. You have control over insulin sensitivity.

I wish I could sit here and tell you that there is a proven anti cancer diet or that if you do example t of exercise per. Week, you're gonna knock at cancer. We just don't have a fraction of the control over cancer that we have with cardiovascular disease.

We we don't understand the disease well enough. So we don't understand kind of the initiation process and a propagation process. And we you we have to rely much more on screening.

Are there good whole body screens for cancer? In other words, can I walk into a tube and um or cylinder rather and get screen for the presence of tumors any and everywhere in the body outside the brain.

because the brain is little harder to to get to right .

I believe that the brain is really pretty easy to screen for .

so fast floating in water well and also the head. When you put the ad to an M R I scanner, there's no movement. Uh it's the least motion artifact is in the brain so when you use something called diffusion waited imaging with backgrounds attraction in an MRI, a technology that was actually pioneer in the brain for stroke identification um it's also really good at looking for tumors as well um so let me make the argument for White screening matters because this is again, kind of an area where I go far down a rabbit hole in a way that I think traditional medicine would argue against. So my argument for screening is an argument at the individual level and IT goes as follows.

To my knowledge, there is not a single example of a cancer that is more effectively treated when the burden of cancer cells in the body is higher than when IT is lower. Uh so the two examples I think I talk about on the book are colon cancer and breast cancer. So when you take an individual with stage four coleen cancer, that means that the cancer has left the coin and is now outside of the coin.

So it's usually in the liver at a minimum. Potentially the lungs are in the brain. That person's five year survival is very low.

They're ten year survival is zero. We will treat them with a very aggressive regiment of multiple drugs. And again, you'll get a five year survival of maybe ten to twenty percent.

And by ten years, nobody y's alive if you take a person with stage three, colon cancer. So the collen cancer is big and it's even in the limp nodes around the Colin, but at least grossly, you can see colon cancer cell. You can see those cells in the liver microscopically.

Of course, we know there are there because if you don't treat those patients, they still die of colon cancer. But you wake them with the same chemo regime that you are going to give the meta static patients. Eighty percent of those people are alive in five years.

So night and day difference in survival. What's the difference in the person with metadata cancer? You're treating a person with hundreds of billions of cells in the adjuvant setting, which is what we we call a adjuvant ant.

When you treat people who have only microscopic disease, you you're treating billions of cells. The same is true with breast cancers. So we have the clinical trial data to put them side by side.

So rule number one is don't get cancer. Rule number two is catch cancer as early as possible. If you're onna, get IT, which brings us to your question of how do you screen for IT.

We basically screen the first line screening is is imaging as a sort of visualization. So you have cancers that occur outside the body that you can look at directly. So skin cancer, you can look directly at the skin, uh sofa geo gastric colon cancer are those are outside the body, right mouths to anus embro logically is outside the body.

So you can put a scope and and you can look directly at the cancer. But for all other cancers that they are inside the body, yeah you have to rely on some sort of imaging modality. I um although now we're starting to look at things things called liquid biopsy.

So blood tests that are looking for self DNA and the self DNA gives us a sense of based on the epigenetic signature, what you're looking at, hey, is there a cancer in the body? And if so, what tissue is potentially coming from based on these epic ic signature? So the problem with relying on any one modality is a is a problem of sensitivity and specificity optimization.

Now with M R I scanner, which are in some way is the best way to do this, because they don't have radiation, so you don't want to be incurring damage as you do this. The irony of doing a whole body C T scan screen for cancer is your p. Your whole body C T skin would be closed if you know thirty to fifty million severs of radiation tagging some of radiation.

So does that mean that people should start to pull you off this? But I was going to ask about this anyway, avoiding going through the whole body scanner at the airport, noise so low.

So yeah ah you know, going through a whole body and at the air porter, even getting a dex. And I mean, these are trivial amounts.

What about flying here? You more more cancer if you're a pilot who's flying .

over the north pole back and forth and back and forth, you're probably getting, you know five to ten ten million savers a year. The nc suggests that nobody should get more than fifty million savers a year.

So you and I both travel a fair out. But typical vel for the busy person, let's say, two round trip flights of more than two hours per month, an international trip every three months.

probably still less than a million sever to year. Yeah, living at sea level, one million sever a year living at a mile elevation. If you live in denver, you're two million sever year .

but I have to ask, stand in front.

I'm just where .

we've got friends. They ask with or .

without tests on the counter that's an inside .

joke that unfortunately unfortunately deserves no description and Peter is not referring to me um but people worry about other sources of radiation. So dozens sound like the microwave is a concern. Um what are the other major sources of radiation?

I mean, outside of sort of nuclear stuff where things go.

yes, look near a plant where there's .

been it's been it's mostly at the hands of medical professionals, right? It's the city scanner and the pet scanner, our hands down the bigger source .

of what about the x of the dentist when they were behind the all but .

under the they're low, relatively speaking of floris copy is very high. Um they tend to try to cover up all of you that so for example, if you if they were doing a photo scope c study of your kidney because you're a stone, or if you were getting an injection into, you know if they were doing A A floroscopy guided injection of one of your disks in your neck, that would be a locally pretty high dose but they're going to cover the hell out of you elsewhere.

And again, if if you get one of these things is not the end of the world, but but I wouldn't want to be getting one a month. And and back to the point about screening, you know a chest abdin held this C T scam is probably, I mean, look, is probably a scanner out there. Now it's moving fast enough that it's much lower. But I give you example o remember how I talked about we do city and diagrams on all of our patients for coral artery disease um and off the shelf scanner for this is twenty million six of radiation OK. So calibrate .

calibration because forty .

percent of your annual allotment .

oh well so the medical practitioners really are the the major culprit here.

That's right. So what what we say is, and I think most doctors are now realizing this is no, no, IT believes you to pay a little bit more to go to a really good place that can do that scan for two million severs, meaning they have a much faster C T scanner, much Better software, and they're Better engineers, so they have Better engineering that they can do on the scanner to get that done.

So so I, if someone listen to this, here is my take, do not get A C. T. Scan or any imaging study without asking how much radiation am I seeing and if a person can't tell you how many Milly seawards of radiation you're being exposed to, then just I am in a way to me until somebody .

can tell me that I relax.

And keep in mind fifty if you you know if fifty is the most you should never be exposed to in a year. Uh, there are Better be a damn good reason why i'm going to go at twenty five in a day. Now there are some people who have to do this if you're cancer patient and they're scanning you as a part of your treatment, I mean, you know you have to pick and choose between those two, those two opportunities. So I don't I don't also don't want to create some fear mongering where, oh my god, if you hit fifty and year, your host, no, it's just, I wouldn't to hit fifty a year every year for my whole life. And I certainly ouldn't want to be hitting hundreds a year for any period type.

I think you were just trying to raise awareness and and also calibrate people to you know what the sources are and and so they make can make a choice not um to place them in to his chronic state of fear.

even in acute data. That reason we prefer M R I scanners because there is no radiation.

I realized this might sound like a specialized circumstance, but i'll just start off with my own, which is, yeah, when I was a graduates, do I um worked with fixed ves, perform the hive, therefore, excuse me, glue l hide. We know that these are mute gents, the immutable cells, not good. You do some molecular biology and love, use DNA and turkle ating by those little bands.

And jail s the reason they labels, because they get between the DNA, not good if to get into your own DNA. And that's a very specialized circumstance. I also injected the radioactive polling into the animals and thinks that sort, again, very specialized. And yet most people, I think I will be exposed to pesticides. They'll put IT stuff on there alone, or they'll have painted fingers and things that sort. Is there any sense of what the average, if one can average risk um is incurred in terms of car in just through interaction with um you know weed killers um paints thinner um detergent around the house that you know we now know there's some major laws' its have been successful against the the manufacturer these things um and what is the real cancer risk are created by having those kinds of solving and pesticides and things around I I don't .

think I know truthfully, I I think it's very complicated to calculate such things when the when their ubiquity is so high. Um so so one one argument is, look, it's kind of baked into the baseline prevalence of cancer today because these things are so ubiquity.

yes. As best in california for whatever reason, seems that there's in his best as warning. I'm prety much every building, if you look carefully enough, except maybe the ones built in the last five years, I don't think i've ever worked in the building where the elevator was updated in terms of the inspection was always like ten years back.

You will see IT while you're in the elevator. No one seems to worry about those or where there was not in asbestos warning or a LED warning. This seems like that is just kind of everywhere and and they're noting IT in these little flags. I I don't walk around worried about I don't sleep over IT, but that sounds like a real risk because they wouldn't ther right clearly, they're just trying .

to cover yeah they go more than anything at this point. I I don't know how much of a risk is best as poses when it's not being agitated. Other words, I don't know that the asp is in the ceiling. You know four layers up is really a problem. But if they had to come in here and rip this, you know, ceiling apart, I don't know what I want to be in here either.

I was like, post nine eleven and law, the work, they are still that the world trade center pits, because that's what was left, sadly, were developed. The cancers right proudly from exposure .

to those kinds of, well, I I would arrest unbelievable amount of pollution, micropolis lotion that was in the air following those things. I me, that's devastating stuff. So yeah, those are those are, fortunately, the outlier events that are at are dramatic.

but. Again, my my focus is basically, look, I could hermida ics, see myself somewhere in the world. Maybe, and maybe that would reduce my risk by one percent or, but i'm going to focus my energy on what I control, because that's really hard for me control.

I like focusing my things on. I like focusing my energy on things I can control. What I can control is the, uh, timing and frequency of my screening.

That's I can control my genes anymore. Um they are, they are. I got whatever predisposing cancer genes. I'm gonna um I might be lucky in this regard and that I seem to get all these horrible heart disease genes and maybe not as much but you can also argue I got there are cancer bad genes in me that we don't really know about because everybody was dying apart to see so Young um but boy, i'm going to a control the .

screening thing what what source of genetic screening do you recommend to your patients? Because there are a lot of them there's yes, twenty three me. There is a sequencing place you available now variety format.

This is actually one of the questions our research team is working on as we speak. So um where we're trying to decide move. So we do genetic braining for certain things like A O E, A gene we wanted know and .

everybody um for its role in large general disease correctly.

specifically in alzheimer disease. But we are selectively using cancer screening in some patients. But in our practice is less important because we're generally so aggressive anyway that IT turns out to be a little bit mood. We don't learn a lot in the genetic screening that's changing our screening practices because we're so throw in our family history and we're so aggressive in everybody regardless of family history. But I think there is a place for these things.

For example, if you're looking for reimbursement on certain tests, you given example, right? So coin cancer um historically was not covered by a colonos py screen for colon cancer, was not covered until you're fifty, has been bumped to forty five. We still think everybody should be screamed no later than forty.

No, I vente had one, so I supose I .

should yeah I mean i'm fifty and I pad we already. So again, why? Because colon cancer is not just the third leading cause of cancer death. It's a hundred percent preventable.

why? Because every colon cancer comes from a polyp, and every pop can be seen on a colonoscopy. So there is simply no reason to not know that.

And that has to be weight against the cost of the colonography, both the financial cost and the risks, which are very low but not zero. Um there's a risk that comes from electorate abNormalities and hyper attention from the below prep. There's a risk from the sedation and there's obviously a risk of bleeding or perforation that comes itself in in a in a generally healthy person.

Those risks are so low that they're almost difficult to quantify as evidence by a recent england journal medicine paper that was a very anti coal and oScott paper, which I won't get in to because it's it's it's um probably little bit of attention. But what's interesting is despite being a very anti colonoscopy aper, this paper does a Better job demonstrating the safety of colonoscopy than anything else. Um IT just um was a oddly designed experiment.

So the biggest chAllenge with aggressive screening posture is the specificity problem, which is when you stack more and more modalities around these things, you're gna start finding things that are cancer. So M. R. I has a very high sensitivity in english. That just means if a cancer is present in MRI is very likely to see IT um but he has a very low specificity which means in english I will see a bunch of things and think they are cancer when they are not and its most troubled by glenville er tissue. So glenville er tissue is the a killed heel of M R I.

And therefore, when you use as we do whole body m for cancer screening, we tell our patients going in like twenty five percent chance we're going to find something that is not cancer but will require us to do further investigation if you're not cool with that, which is totally fine, we're probably shouldn't do this. And again, most people are okay with that. But IT helps to set that expectation go again that you're gonna probably be chasing your tail looking at some stupid firework module.

That is absolutely nothing. I mean, I can't tell you how many useless die right now, les. We've had to get ultra sounds on that proved to be absolutely nothing. And you to follow them for a couple of years .

to make sure that nothing. What is the typical cost of a whole body? People who are not pay, how would they go about getting those? Because I think most people's general practitioner is not going to script that out for them correct?

Um I don't know the short answer because I don't know how many different places are doing that. I can tell you that we use a couple of different facilities and I should disclose that i'm a founder of of one of them. Um but we use a scanner that probably. We send our patients to any anywhere they want to go, but within a certain company that we like um that's not a company I have an affiliation ation with, and I believe they are charging about twenty .

five hundred dollars. Can you since you don't have an affiliation, can you mention that because prince, you are not my physician sadly for me and luckily for you um but i'd love to get a whole body MRI um so what where can I what is this company?

So the the company that that makes the M R I that that we are using right now is called premium val. Um so I I interviewed the chief technology officer in the head ideologist uh of that company on one of my poddar sts um the super interesting technology based out of vancouver and for a long time that was the only scanner in the world.

So I had my first scan and back in two thousand and fifteen I went up to vancouver to get that done, probably had my first two up there. They've now opened locations all over the country, so they've got have got one in the big area. They would ve probably got one here in L A.

Um I know they have one in dallas, so we've them all over the place. great. And then the company that i'm infilling ated with is a different type of company that does all sorts of diagnostics. But among them is we have a prenez val and that company that is called .

biography and the bio PH ocp spell as one one back. yes. No, that's very helpful in terms of understanding the general risk and waste offset cancer to extend one can and certainly what what the consideration should be.

Number three, on the list of ways to die, you just titled this ways to die, or we should tittle this, how not to die too early neurodegeneration disease. This is an area somewhat familiar with, not because of my own experience, thankfully, but because of my relationship to the news science community. And last time I checked, I I was told that everyone experiences some age related cockin have decline.

So we all get less proficient that focus memory complex, context dependent test to achieve all that stuff as we get older. But it's the slope of that line that really can be controlled to some extent and that alzheimer dementia represents just a steep acceleration, downward acceleration of all of that. That was what I was told.

I'm guessing that even though I reside that kind of but i'm reside in that community that some of that is being revised, especially with respect to the underlying causes of alzheimer's because there's a lot of controversy, even scandal around this whole A P P A bob um malloy black tangle stuff wishes the stuff of text books, medical students and neuroscience students. What is the story with neural general disease, alzheimer's in particular? How can we offset IT? And perhaps as importantly, how can we all slowed our own cognitive decline, irrespective of whether or not we get what .

is called alzheimer's dementia? So alzheimer's disease is both the most prevalent form of dementia and the most prevalent neurodegeneration disease. So IT occupies that unique spot. Um we're talking about roughly six million people in the united states have alzheimer's disease.

That's one in let's see I mean about two .

percent of the total population OK, but that doesn't include those with mild cognitive impairment or dementia or other forms of dementia. And of course, the right metric is not one percent of the population, which of course includes children. Things like that is so .

function of age is age. The major risk action for the alarms, like we say with glaucoma, the disease are much more familiar with because my life worked on IT for many years. The biggest restriction tor for getting gloomy is h 这样。

The greatest risk factor for cardiovascular disease is age. The great test respect CT for cancer is age. Um we tend to not spend a lot of time talking about that because it's not a modifiable risk. So you know we we tend to focus on modifiable risk factors.

Um so what else can we tell you just to give you kind of layer the land? So the second most prevalent neurology, general disease would probably be li body dementia, followed by parkinson's disease, although the rate of growth of parkinson's disease is the highest, so that we would probably be most. You, we, those three diseases, we want to really be paying a lot of attention.

You, as you know, there are a lot of other neurologically diseases. Every one of these things is devastating. Like multi gross A L S hunting sees either awful, awful diseases.

Um there are also other kinds of dementia. Vascular dementia is not alzheimer's dementia, but IT is IT produces comparable symptoms. Each of these things, by the way, are slightly different.

Li body is a dementia. It's a dementing disease but he also has a movement component. So it's sort of sits on a spectrum that's so you know I mean loosely halfway between alzheimer disease and parkinson's disease.

Um we talk obviously about age being the number one risk factor, kind of not that interesting because can do anything about IT. So the real goal is as we age, what are we doing to reduce risk? Um well, let's start with an important gene.

The gene that everybody's heard of certainly came up a lot on the limitless special where Chris helmsworth was um you know made the decision to reveal something that none of us expected when we started that whole series, which was that he ended up being homozygous for the A O E four as a form. So um maybe folks understand we have two copies of every gene. So for gene x, you have copy that you ve got from your mom and copy that you got from your dad.

And the apo e gene is kind of a unique gene. And that IT really IT has three different ice forms that are all considered Normal. None of them are mutations. So you have the e two ice form, the e three isa form and the e four isa form. The e four ice form is the og ice form.

That's the one that we have historically had as far back as we can go, which I think the e four ice form offered a lot of advantages back in today. It's a bit of a pro and flaming um I A form and IT certainly offered protection against infections, especially parasitic infections in the C. N. S, which would have been a .

really important thing to select for two hundred thousand years ago in take back. But I mean, IT just seems like parasite and other tissues would be issue because what retry by the brain disease? Yeah yeah IT IT probably .

offered some protection outside of the brain as well. Um anyway, the the e three I have form I think showed up, I think fifty thousand years ago. And the e two ice form showed up very recently, about ten thousand years ago.

Now today we realize that there's a clear stratification of risk when IT comes to alzheimer disease. The tracks with those ice forms. So because you have two copies, you basically have six combinations of how you can combine those genes.

You can be two, two, two, three, two, four, three, three, three, four, four, four. Um the prevalence of them is basically as follows three. Three is now the most common, three is the most common.

So double three is fifty five eight percent of the population. The next most common is the three four. What's about twenty five percent of the population? And then after that, most things are kind of a rounding error.

So, uh, two, three and two fores, we would be the next most common. Four force are very rare, and tutus are the rare list of them. All two tools are less than one percent.

Four, four years, about one to two percent. Um very important point here is that the e four genes are not deterministic. So they're highly associated with the risk.

They're not deterministic. There are at least three deterministic genes in alzheimer's disease. Uh one is called psc and one one is called P S E N two and another one is called A P P.

Those genes collectively make up about one percent of cases of people with alzheimer's disease. So they're fortunately very rare genes. But sadly, they are deterministic.

Meaning if you have those genes, you do get alzheimer's disease. And what's perhaps most devastating about those genes is how early the onset is of the disease. These are people that are usually getting alzheimer disease in their fifties. Um so we do with a patient in our practice actually he is spoken about this very openly um whose whose mom had one of these jeans um and you know got alzheimer disease in her early fifties was I I think you might have made IT into her sixties before he died, but you know absolutely devastating consequences here.

Why do people all summers die? Because I know about the high cample degeneration. The campus across be an area the brain important for learning and memory. But is there brain stem ty generation? Do they lose breathing centers are usually .

what happens is it's sort of failure to throw aspiration, things like that. Yeah so it's usually they just stop eating um or they can control secretions. They asked they get in a monia or they really lose the ability to even sense like pain in their body and therefore like they'll get an also and they don't realize IT and it'll become elected and i'll develop a horrible infection and response to IT.

I see. So it's a body vulnerability. The reason, as is everyone's while a news report will come out and based on a legitimate and case study where um they'll do a scan on, some person discover that they're missing literally half their cerebral cortex like huge chunks of brain and they're functioning relatively Normally. And so here are talking about an order of relatively it's widespread but there a few hot potts accounts in the brain that to generate more are profoundly dly than others and in the people dying so that makes sense IT extends to lack of preferred warehouse or control and then some some acute injury or election.

Um you mentioned earlier some of the controversy, right? So what what do we talking about here? Well IT IT that I I do write about this at links in the chapter on alzheimer disease because I think this is a very important point, right, which is the index case for alzheimer disease.

There was always an index case, right? The the the coron copah ent zero um the index case was a woman who, you know, a one hundred years later, we realized had an APP mutation. I was there A P P or p sc n one, but he had one of these deterministic genes that LED to a very early onset of disease, which, by the way, without which we may not have come up with the diagnosis.

Because had SHE just got alzheimer disease in her seventies, IT would have just been referred to a silly which is you know was not interesting enough to pay attention to um but I think IT probably set the field on the path towards an over emphasis on ema oy beta and it's not really clear. How important emilia is uh h which is not to say it's not important IT is important and there's no ambiguity that emo aid is responsible for the um the changes that we see in the brain. But it's not Crystal clear because there are lots of autopsies that are done on people that are completely healthy and have died with no cognitive experiment and they're chockfull l of emo yd. So what we don't fully understand is exactly what does removing maloy due? Um the other thing that complicates the story is there has been no shortage of drugs that target emo aid that have seemed unsuccessful.

And to clarify, when you say employ, you mean people have died with their brains. Examine in autopsy, see that there are tons of so called employed places, correct um different than uh arterial places of course, but within the brain so the two hallMarks of alzheimer's uh history pathologically would be relax and tangles um and even that now is course coming under under question um but for it's what we teach every new science yeah graduate students is what we teach every undergraduate. It's also what we teach every medical student um and conscious it's stanford but everywhere uh so I have heard that the link between APP and whether not one develops genes for related APP and whether not clear at one side or another is just what you are describing and risk for all time.

It's basically which question right? People with the APP mutation, I think have one extra lavage site, the result in one extra clavet amalwin. And then at misformed and the this folding is is what the black is is being created that also then pretty disposes them to the neuroscience lary tangles and again but all .

this is under question now right? I mean this is what I was told and when I look IT sounds like there were some early there were some papers early in the chain of discovery um and the research alzheimer's that um were either wrong because they were falsify .

there in falsified paper on one particular eloy uh variant and that clearly set the field back a decade because a lot of people went down that rabbit all based on deliberately falsified data um then what happened to that guy?

I want to I want to I I I was a guy, but what what happened to that guy?

Yeah that's a good question. Um I think I wrote one piece about IT when IT happened, I actually reached out to the person who broke the story because I wanted to have them on my podcast. And I forget why he didn't do IT. I forget why he he wouldn't commit to IT or something like that I thought was a little odd because I thought this would be a great way to talk about this.

Um I do not know what came of that scandal in other I haven't paid attention to IT for a probably nine months so I don't know you know obvious ly, the papers probably been recalled, but I don't know what disciplinary action was taken. The field is. I don't know.

I don't want to speak like i'm in the field because i'm not. I I want to be careful what I say, but I I think the field is probably in in a bit of a crisis because there there been so many bets placed on anti Emily ID therapies and employed biomarkers and employ yed everything. And we just haven't seen efficacy, right? So contrast that with cardiovascular disease, where, you know, you have this bob biomarker, you you understand the path of physiology, of how IT works.

You have drugs that target IT, so you have a biomarker. So you give somebody a drug that lower S A O B, you can measure O B. That's a really important and obvious thing to be able to do.

And then you have clinical outcomes, which is, oh, when you take a bunch of people in primary prevention, IT takes this long before you see an effect. In secondary prevention, IT only takes this long to see an effect, right? Different risk ratifications.

All these other things, we don't have any of that for alzheimer disease. So we do use there are now serum employd biomarkers that we use, and we do track these in our highest risk of patients, but only because we believe, I don't know for right, by the way, that lower is Better. And therefore, if we make these changes to you and your serum, Emily ID levels come down, that tells us something about what's happening, your brain that's favorable.

But I mean, I would hate to represent that we are practicing nearly the level of precision medicine there that we are in cardiovascular medicine when IT comes to alzheimer disease. Maybe take a epic when IT comes to brain health. I think there are handful of things that seem unequipped true, and there is a lot of stuff that is signal to noise, is racial, that's really low.

So the unequipped true things for brain health are sleep matters. Another unequivocally drew thing for brain health is that lower L D L collection o in a poo b is Better than higher. Another thing that is unequipped true is not having type two diabetes matters .

to having really being.

instead.

the inland sensitive .

size matters. Sleeping adequately matters. Having lower lipids matters. Those three things are clear. And the fourth one, IT is unequipped clear is exercise matters, more specific .

form of exercise.

And very, I am. So i'd try to answer this question on a recent A M A that I did, because the answer is, more is always Better.

But if you, if I, I tried to have one of our analysts look at IT through the lengths of if you could only exercise three hours a week, what would be the highest use case? And our interpretation, the literature was, if you could only spend three hours a week exercising, you'd be best off doing one hour of low intensity cardio, one hour of strength and one hour of interval training. So if someone to said, like, I only want the minimum effective dose, you're gna get a pretty good bang for your buck doing that. I would argue, if your brain really matters to you .

do more one hour of general trainings .

no joke no because you're going to spread that out of her probably at least two workouts yeah um but under those four things are basically the only thing where there's there's no ambiguity about the benefit.

What my head hits don't don't .

hit your head seems almost assured you in a accept ble individual for sure um so I put that yeah maybe we could include that as well. I just want .

you know one of the things have been learning recently. I know you boxed um for a number of years when you were Younger. I boxed a little bit, hit my head a number time skateboarding.

But you know we think about sports injuries is the major cause of head injuries. But then i've got colleagues stanford car accident by bike accident. I've got so many colleagues and children of colleagues growing up in around campus that were hit by cars on wedding road, or you know that mean small objects surrounded by you. Three was a car with three thousand pounds or something like more, you know, IT. It's unbelievable, the number of hinders and then construction sites because as ridiculous little hard hats which um don't protect against anything except um I don't know maybe um when blown hair that they they basically pretty proposed the whole situation predisposed sed people to head injuries very common on construction sites and um saying nothing of military at sea so I think that I was told that the the best thing to do if you get a head injury um is to not get another one in other words, if you can stop doing the activity that leads to more .

head entry yeah the other thing that I think is emerging, and I hope IT is studied rigorously, is the use of hyperbola oxygen immediately following A A tbi mamma's burn injury. Respond to um dome degas in a little while I go to of because he knows a lot about this lid um to say, hey, hey there are anything out there that's really kind of turn key convincing and he said not yet um they're still doing that right? So I I would do this if I if I was a car accident tomorrow and sustained a concussion and but i'm not a proponent of hypermarket oxygen.

So I we have an internal White paper that we wrote inside quite recently where I examined when I say I examined you know the analyst team examined and I push back and reviewed um and I I came away very kind of barry shh on hyper beric oxygen. I don't think I don't think it's harmful, but I think all of the claims are nonsense. Tell your extension is totally irrelevant. If you actually look at the studies, the worst done studies have ever seen in my life, i'm sure you've seen some some of these where it's like you put these people on harberg chAmber and then watch them do cognitive tasks act after there are so much Better well define printers, they don't even have placed o groups here. Can you imagine doing a study without a policy group or your placebo group doesn't go into a shame chAmber?

Yeah I mean one of the big problems, the proliferation of all these paid to play journals mean jill, that will basically publish a paper with minimal al poor poor review um because they charge in order to publish um and then offer free access. Free access sounds great, but when is paid to play type drills? There's been a huge proliferation of papers.

Most of what you find on twitter in which the study design is, is beyond bad. Like a nth traders who woke up late for school and was parting all weekend could design a Better study than most of these studies. And there are some excEllent studies out there as well, of course. But first and eventually on hyper berry chAmber too. I'm not picking on hyper berry chAmber per sale, but the deliberation of of truly terrible science that's published in peer review journals is is just overwhelming .

yeah it's insane. And all of that is to say I think there are places where hyper beric oxygen makes sense clearly in wound healing IT does it's it's a miracle treatment for wound healing and I would absolutely use hyperbaric ox identify suffered concussion. Um but you know beyond that, I think it's pretty.

pretty tough to make the case. Where do we people go for that? I mean their .

clinics .

and clinics you into a .

real chAmber. Um I think the T B I protocol is most commonly used is god. I want to say it's pretty intense. It's like five sixty minute sessions a week at two atmospheres oh boy like it's not it's no joke. Um so from a cost and time perspective, it's enormous.

And in the time and cost are reasons why I think when I see people doing hyper berry oxygen just because they think it's going to help them live longer, i'm like, dude, you know what you could do with five hours a week plus the commuting time that you put into that? Like put that into exercise and I promise you, you'll get a bigger benefit then you're getting out of hyper berry oxy. But there's a lot of other stuff that I just think is maybe helpful.

There's tons of supplements that I think about when IT comes to brain health. You know what about theou man? What about magnesium? With l three and eight the transporter um we're about methods ted vitamins that lower homesite.

What about E P A N D H A? And we've gone through all of the literature on that stuff and many these things we still are recommending through a kind of basically like the potential benefits outweigh potential costs, but the evidence is really an impressive for most of those other interventions. So when you think about the big four or big five, if you include not getting head injury, everything else is probably rounding error compared to .

those big ones, maybe just for sake of of there. And as we can just list off those four, again, exercise.

exercise, sleep, insulin sensitivity and lipid management.

Well, along lines of head injuries, we should probably ved to the next category of how not to die as to avoid accidental death. How common is accidental death? And what are these accidental death? S because we are separating this out from automotive death.

So this people um falling while hiking self is gone bad. No, what are we talking about here? I'm not chocolate because I like it's just I mean, that seems like there's a near infinite wait wait to to die accidentally. Um I want you think there .

are two ways to kind of look at this um and so here I kind of merge two categories. Um so I would call IT that that overlap in the way that they're characterized by the cdc. But I would sort of we will talk about them separately and bring them together.

So if you talk about true accidental deaths, automotive and falls and overdoses are the are the three that's basically what IT comes down to. So you know, when our death bar analysis, we kind of list all this is out. In fact, I think that's actually one of the figures in the book is I have the accidental death figure that we've put together where we've adjust that by population.

And you'll see a couple of things. If you look at IT in absolute terms, it's basically a pretty constant. So regardless of what decade of life you're in once, your above, you know twenty accident of deaths are a pretty sizable number of of debts. Now car accidents seem to be pretty constant throughout life, little more common if you're under sixty than over sixty but they never go away.

I was told that um in teenage and boys and boys and their in the early twenty years, alcohol induce the uh automotive fatalities. But police and IT IT is an astronomic risk is just not true. It's not true anymore .

compared to over those because Young people .

now um aren't getting their driver's licenses .

of yeah well, I think it's also because we're seeing such an uptick in the deaths that come from general got IT. So final related deaths have basically squashed all other deaths below sixty five on the accidental front. Really, oh, yes, it's not even close .

because of the number of different substances that fenton al is being .

well in the way into everything. So counter fit drugs, all of this IT drugs. And look, most of the time you're not getting a lethal dose, so you know but but you're getting lethal doses so often now that um well and I did a little analysis actually the other day when I looked at how are deaths of despair increasing over the last five years.

So what do I define as a death of despair, suicide, alcohol related death or overdose, accidental overdose, so that we differentiate that from suicide where suicide is obviously deliberate and accidental is not. So if you just look at those three things, so accidental overdoses, suicides and alcohol use or alcohol related death um not including driving by the way, this is like sorosis of the liver that comes from that number is going up at almost twenty percent per year since twenty nine. So though I couldn't get twenty twenty two numbers yet at the time of time, I did this analysis, which was last week um the twenty twenty one numbers was about two hundred ten thousand americans .

up from .

one hundred and eighty thousand and twenty and twenty up from like a hundred and fifty thousand twenty nine .

so is this um and that .

is driven almost entirely by fatal use.

So i'm trying to get a sense of how that happened. While back there was an article in the new year time said some photographs of people that died of fatma over those and said they went out to buy cocaine and died of. And I thought to myself, this is really kind of odd social, the phenomenon hand, right, because I mean, here there, they're not demonizing these cocaine users.

I mean, they went out to buy cocaine, right? This is not A, I know cocaine has one narrow clinical use as a prescription drug, but in general, one bill bike cocaine there, parting with IT. You're using IT to work on the hours or something like that. Um so the whole nature of the article .

was a bit strange to me.

but IT clearly pointed the fact that people are using cocaine. Okay, that's no surprise. But people are going on buying cocaine. They're presumedly buying volume.

They are, presume killing. I mean.

but this online, this is a person. I mean, the reason i'm so, so baffled by this is let let me contextualize have said so far about this question, I was surprised that the times would write a paper about the tragedy of cocaine users dying a fentener. And I think I did IT to highlight the vents.

No problem, because people were using cocaine for a long time. And typically those are not the members of the population that will really focus on, since the admit da is the local cocaine and crack epidemic. So basically tells me that people like you said, illicit drugs of cocaine, but also, you know what other source .

of drugs are people major of dying from final poisoning. And I had a guy on my podcast recently in Anthony y. hipolito. And if anybody y's interested in this topic.

they really need to listen to that, watch the tube. You actually, if you're interested, would be interested .

in if if you have a child or know somebody who has a child, you just got to get this podcast into their hands because it's the most important public service announcement i'll probably ever do in terms of saving more lives potentially. Um where the majority of this is making its way into the into the accidental poisonings is through illicit counterfeit pills. So it's when kids are out there buying you know oxy they want oxy.

Well, they can they can get real oxide, right? Because they're going to go to a doctor and get real oxy. So they going to buy IT through you snapp chat.

They're going to buy a through some drug deal that are finding on social media. Um they're buying sleeping pills. They're buying all sorts of counterfeit stuff like at all. Any of these things are being based with final ado. absolutely.

Well.

assume again the reasons are it's insanely cheap to use synthetic final. And secondly, and but the effects .

of ending all or nothing like effects IT at all. So cocaine doesn't make sense for that really sense here.

And yet it's still showing up in cocaine again. I I don't think that's the dominant place is showing up. I I would guess that the dominant place is showing up is in counter fit opiates.

So any open orbit you at any time.

let me tell you what i'm telling my daughter, right? This is to me it's a front line problem. I A fourteen year old daughter, i'm like, listen, I don't care which friend is IT is I don't care how much she's amazing if he tells you to try this sleeping pill because he took at the night before and I was really helpful, or this will help you study Better, or this will help you do anything.

Am I just come to us what we ve got a Better pill for you, right? Like in other words, I you can't trust anything because you don't know SHE got IT SHE has the best of intentions, i'm sure when he is given to you. And by the way, he probably took up the night before, I was just fine.

But the people who are making these pills are not exactly of the G. M. P. standards. So you know, you just have no idea which pill is getting what dose.

No one thing that Anthony had told me that I simply couldn't believe I had asked him six times, was that some of these pills have like one milligram of fatal in them. Now, I made the point on the podcast that a hundred milligrams of final for most people is a hit like they would like. I've had final before been in the hospital and i've had finial. One hundred milligrams is like, wow, that is such a trip the wire.

people dying from one milligram intake.

respiratory inhibition, you can't breathe that shot the brain stem well.

I don't think we can highlight this enough. Um you know adults dying, kids are dying. I met someone is earlier this week who told me her thirty five old died of a accidentally fant all over the he wasn't, at least by her description, a drug act or .

anything in that sort. Yeah, we're talking about a different game now, right? So it's like, these are kids that have anxiety. These are kids that, uh, you know, are are, are are sort of addressing another issue with with these pills. And that's why I think this this whole concept of deaths of despair is is, is a really important one.

But back to your question, what what do accidental deaths primarily amount to for for the aging population? Then IT is so clear that IT is fall related. This is where once you hit sixty, sixty five, the the risk of a fall that results either immediately in death, you know, you hit your head and die going back to like three bro hedge or IT is the straw that basically leads you down the path.

The death within the next twelve months is astonishingly high. It's so high that it's sort of hard to wrap your head around. But if you're over second five and you fall and break your fema or hip, so you either cracked the femoral neck or the fema itself, you're twelve months mortality.

The probability you will be dead in twelve months after that break if you're sixty five or older, depending on the study, is about fifteen to thirty percent. wow. wow.

So in terms of offsetting the probability of false, you talk a little bit about this um before, but you and I have talked a little bit about this before, but maybe we could go a bit deeper. People's ability to jump and land seems to be highly correlated with ones ability to not fall, or at least fall, and control the fall in a way that a leads to no or less severe injury.

yeah. So andy gell pen talked about this on your as he talked about IT on my podcast, what is the hallmark of aging on the muscle? IT is of the type two muscle fiber that's the hallmark that's to which fast witch muscle fiber.

So if you want to understand what looks different in fifty year old Peter versus eighteen year old Peter, it's not my type one fibers. It's my type two fibers. It's my fast to which fibers is my explosive fibers may, and I was eighteen years old. I could vertical jump over thirty inches today. I'm lucky if I could vertical jump twenty four inches and you know, and when i'm sixty point, it's like my goal is to be able to vertical jump six twenty inches when i'm i've seen .

some videos of some um eighty old sprinters that are pretty impressive and certainly eighty old Jimmy yeah that are impressive. I've not seen very many videos of eighty olds hunky basketball, for instance .

yeah .

who are not more who are not taller than .

six um so so when we lose, you know are so so again, if you just think about size strank speed, we lose speed first we lose speed, then strength. On the last thing, you lose the size. So again, size is diagnostic to fiber, right? You you can have big type won fibers and still have lots of size.

They're not going to be that strong. They're certain not going to be fast. So what I mean, if you go through we could spend hours on this particular topic.

But I think the most important thing that people they do understand is you can not age well if you are not doing the type of training that is there to strengthen and delay or minimize the type to of your type to fibers. So everything matters, right? You have to be doing your zone to, you have to be doing, you know, all of these other things.

But some component of your training needs to be stressing the type fibers. You have to be doing strength training that taxes those fibers. You have to be doing reactivity training. You have to be doing explosive training.

and ideally some training that involves jumping and landing. Well.

jumping is a very big part of IT, and landing is a very big part of another one of, I kind of think of as my four pillars of strength training. So one of the pillars of strength, straining is a centric strength, which is breaks.

So you know, you're gonna hurt yourself ten times more likely and making that number up, by the way, I don't know it's ten times, but experientially IT seems to be, you are ten times more likely to hurt yourself stepping off something than stepping on to something, right? Stepping down versus stepping up um because when you step up on to something, you are concentrating, controlling a muscle. When you step down, you have to apply the brakes.

And that's where most people falter much harder to walk down hill and up pill, up pill is taxing your cardiovascular system. But if you slow down enough, you're fine. But a lot of people don't have the ability to slow themselves down when they're walking down hill.

And so. When an older person steps off a curb and can't fully stop themselves. And that results in a fall.

So, you know, I like doing things like a broad jump, broad jump of fun, little test that I like to do every once in a while. I always want to make sure I can brought jump six feet. That's kind of my arbitrary number that i've chosen.

And the reason is on the takeoff, that's a very explosive movement. But the landing is just as important. If I can't stick that landing IT means I don't have the breaks.

So those are kind of some of the tests I I want to be able to, to make sure that I am utilizing that system because I do think, you know, look, i've watch, I watch my mom. My mom fell. I been about four months ago, just fell in a typical way that people fall um by the way, could have happened anybody.

It's not like, no, my mom walks around, moves around just fine but in this particular day you just tripped on a on a uneven stone and fell and landed in broken hand. And really lucky you didn't break her head. I told to that mom, I M promet seventies and I said, luck, you know, if that was your favor, I i'd give you a thirty percent chance of dying in the next year.

I mean, it's just an on those are such difficult to recover from injuries because first, while you're dealing with the immobility of you know the hospitalization and immobility that follows that and the amount of muscle loss that occurs could easily be you know four, five pounds of lean tissue lost that for most people at age becomes almost impossible to get back. Mattson says nothing about sort of the acute causes of death like a fat emblems. M, that results from a broken female of blood clock from lying in bed.

Those things are also catastrophic. But what happens is a lot of these patients just never get back to the same level of mobility. And you know, now I think in many ways, we're kind of pivoting from what kills you to what ruins your quality of life. And we spend so much time talking about what kills you. But I think but you might as well be dead in some ways if you can't do the things you want to do and if playing with your grandkids or gardening or playing golf or going for a walk with your spouse ser think of any other things that we all do today and take for granted if you can't do those things, I don't know you got to lose the the reason to to be .

around and often times um the inability to do those things is associated with pain that you know which is uh psychologically and obviously physiologically so so distressing. You mentioned the four pillars of health. Maybe just list those off for nothing. The well the four pillars of longevity through physical oh yeah so .

it's of the exercise pieces of them ah yes. So strength, stability, a robic efficiency and um a robic peak output.

A roy peak would .

be view two max in zone two. That's in in my analogy, that's the your zone two is the how wide the base of your pyramid ID is and your view to max is how told the peak of the pyramid is. So the best pyramid has a wide base and a high peak.

So you could have a reasonably wide base and a shallow peak. If you just did zone to training you, you know you're gonna get a reasonable peak, but it's not going to be that high. You have to do some of that specific training if you just focus on high intensity, you might drive up that vio two max, but you're actually going to have a relatively wide and narrow a obie base.

So you think about just maximizing the area of the triangle, White's tallest stability and strength. Stability, of course, encompasses everything we're talking about in terms of reactivity um know I I dedicate a chapter in the book to this concept because IT is so foreign to most people um and in for understandable reasons. It's just it's not sexy. It's not it's the hardest one to train. It's the hardest one to understand but it's so important because it's the thing that I think that differentiates people who age well and and people who don't age well.

And I should um wrap thrown there. Please crack me from wrong. But also most of machines that are in typical commercial games that allow people who are not very experience ed to start doing some resistance training don't really tap into the stability factor terribly much. So well, there's a value to leg extensions and like girls, and chest presses and shoulder presses done with machines, certainly for a number reasons, and can often be safer than freeway ags, especially for people approaching in a later time or or new to the whole thing, they don't really lend themselves to um real life stability. Walking down, as you mentioned, walking down stairs that in the absence of a hAndrail or um or movements in um kind of a odd planes, you know having to step aside to avoid a bicycle at an angle as I was just moving linear arly yeah .

and by the way, a lot of things that don't involve machines still don't give you that right like I mean doing a dead left, you have to be stable to lift a heavy weight like a you would a dead lift without hurting yourself that requires unbelievable capacity to harness into abdominal pressure and to be connected know if you're going to give five hundred pounds off the ground, you're stable.

But that still doesn't prepare you for what you just described. So stability is multifaceted. IT involves doing a lot of things. You know, today, for example, I finish my today was a cardio zone two days.

So I did my cardio zone to, and you know how to extra ten minutes before I needed to kind of get moving. And so all I did was step ups for ten minutes. I just did single leg, very slow step up and insanely slow step downs of a box in a gym.

So two second up, four second down. Two second up, four second down with you know and I would do them with episodic al loads controller al loads author to different things and you know basically that's just a stability game for me. It's like i'm building that concentric strength in um in a movement where it's easy to cheat um but can I do IT with out treating?

It's terrific and it's terrific that you cover all of that in the book addition to these other topics. So several times during our conversation today, you eluded to quality of life and one of my favorite segments in your book indeed the segment in your book that I believe could be its own entire book of tremendous value is the section on emotional health. If you could just share with us a bit of what inspired you to include that section. Was this, for instance, um based on communication with your patients, to what extent he was based on your own life experience? And then maybe we can drill little bit deeper into what's contained in those chapters and what really constitutes emotional health.

Well, I mean, I think that that chapter of the book, which is a pretty long chapter, it's the final chapter as well, is certainly different from all of the others and that there is no, there is no confusion about expertise, right? I think in the other chapters are at least try to come across as having some knowledge on the subject matter.

And I am writing them most often as corn court the doctor, right, because they think that last chapter is is much more about an experiential side of, uh, my knowledge acquisition and and they were really IT comes across more as a patient. And I think you're right. I think that that's a chapter that initially was resisted by all other parties involved in the book.

So my coauthor um my editor, everybody else sort of felt like this is interesting. But it's a it's a separate topic. If you want to write about this, you should write another book about IT.

But IT doesn't really belong in this book. I disagreed for two reasons, and ultimately, I guess my opinion prevailed. The first is, I didn't want to write another book, so I just that not including this in this book, to then write about another book, or is not something I was interested in doing.

But I think more importantly, I do think that this book is about much more than how long you live. And while we have talked about and we will talk about in the book, that is, you know how cognitive and physical health are just as german to quality of life as they are to length of life, this other piece of emotional health, you know, it's potentially the most important of them all. It's also the hardest to define.

But without that, none of the other stuff matters, right? So there's, you know, infinite lifespan. If if if you're miserable means nothing .

may be worse.

That would be a curse, right? You could argue, how could you punish somebody the most, allow them to live for every be miserable.

is there?

Yeah there's was a great god tithonus.

Thus he was granted immortality.

but that's a bit different. He was granted immortality, but without health span, basically. So he aged forever.

dreadful? no.

And this would be dreadful too, right? And then I feel like, why do I need to write about this? Well, I think that, you know, this is probably my greatest struggle.

I think um you know where is the outside of the podcast? You asked me kind of like what are the obstacles to longevity and that got us down a path of some very black and White things. But when I look at a patient, I create a dashboard. And the dashboard is, what are all the things that are a threat to every component of your longevity, both lifespan, health span. We talked about a bunch of things.

So how what is what is your risk for rah risk grosses? And what are we doing about IT? What is your risk for cancer? What are we doing about IT? What is your risk for neural generation? What are we doing about IT? What is your risk for accidental death? What are we doing about IT? What is your risk for physical decline? What are we doing about IT? And one of those things is what is your risk of emotional health or poor emotional health and what to be doing about IT?

Um so when I do that exercise for me, which I I do, I mean I can I have that spread sheet laid out for me and I know where my factors lined up. And interestingly, despite my family history being horrible for arthritic k roses, it's like six on my list because I mean, basically I intervened early. I have a clear understanding of the path of physical ology and i'm doing everything to the maximum.

So i'm actually very confident I will die with and not from at risk, rosas. But the hot thing on my list is actually emotional health. That's the one that is the hardest for me to manage. And IT is the easiest to get out of baLance and that creates the most pain in my life. So that's that's a long answer to why I felt this needed to be in here .

or in the book. You going to a very honest detail about some of your journeys through and chAllenges with emotional health and pasta overcoming those. Maybe we will get into those a bit.

But before we do, how shall we define emotional health? This to me seems like one of the most difficult areas to calibrate oneself um like even just measuring emotion is tRicky a language is the dissection tool for psychologist, psychiatrist and indeed for all of us. You know, how are you doing today? Great or a miserable or i'm depressed? I mean, mean such different things to different people. Obviously suicide being the far end of of, we presume misery, mean there are instances of manic suicide, but you know, depressive misery. But setting that aside, I mean, how should we think about and communicate emotional health to ourselves into to the relevant people that could potentially help us?

Yeah, you're right. It's it's it's very difficult, right? And and so much of what goes into this book is about things that are much easier to quantify that I can sit and talk for days about all the ways we quantify from the histologic to the growth of each of these diseases, genetically, all of these other things um with the emotional health, it's it's far more ague and I don't even attempt to come up with the definition right.

I can tell you things that make up components of IT. So connectivity with others just seems to be an unescapable part of this. So the ability to maintain healthy relationships and attachments to other people, having, by the way, these are no particular world, having a sense of purpose, uh, being able to regulate your emotions, experienced ing fulfillment, experiencing satisfaction um all of these things matter.

And I think that for many of us, if we're taking an honest a appraisal of ourselves, we'll notice that we have deficits in these areas are being present. By the way, that's something that may have been less of an issue one hundred years ago than IT is today. So I think you know for certainly for me, being present is very difficult. It's not my default state.

I don't know that it's the default state for most people truthfully um but i'm very often predisposed with thoughts about the future, occasionally thoughts about the past, but it's much more of kind of thoughts about the future and planning and thinking about what I need to do and what do I want to do next and never really being satisfied with anything that's happening the moment. So I have to work hard to kind of overcome those things and i'm sure you can appreciate this. But when you are present, you generally hear in a much Better frame of mind.

Yeah, there's an interesting study I think he was initially published. Dan gilbert slab, one of these long term happiness studies there was polished science magazine that pink people, for their level of happiness, unhappiness, presence or lack of presence, multiple times through the day. This was in the early years of smart phones.

So this is around twenty ten, twenty eleven. So the technology wasn't as good as is. Nobody was good enough to do this in a very large number of people. I forget how many, but it's certainly more than ten thousand. And problem that number is stating intentionally low.

And what they found was, regardless of whether not people are doing something they enjoyed or not, boring to them or not, the degree of presence to what they were doing was a stronger predictor of their happiness in that moment. And overall, there was anything else. Um and also a pretty fairly rare feature for most people.

So seems like it's something that we do need to work at perhaps nowaday, as you point out, more than we perhaps do in our ancel past. Yes, i'm a little bit surprised that um you say that you find IT hard to be present because you strike me somebody that um is not just willing but as A A strong um almost reflects toward drilling. You observing that the counter is something and then really drilling into IT and then really getting to the the guts of most everything that that interest you. So you struck me in somebody who's very present. And I guess maybe this gets .

back to this vial exclusive. I mean, I think so. For example, i'll notice that sometimes if i'm playing with my kids, especially my boys, because they're Younger, right? And playing with them is really being in their world.

Like if i'm with my daughter, we can be doing things that are kind of mutually like you. We'll do things together that I would probably do by myself or you would do by ourself. But with my boys, it's generally doing something I wouldn't otherwise be doing. And i'm if i'm paying attention to IT, i'm constantly amazed at how after five minutes of searching through a bin for just the right lego piece that we want to do to build this, one little thing like my mind will start thinking about something else like, oh, my god, like, I got to go.

I didn't email that, do back and I got to do this, and I got to do this and I ve got to do this and I got to do this and I just get into, I got to do, I got to do, I got to do. That's I do. You've only been here for five minutes.

Why don't you just find the lego peace that you need to finish building that thing over there that is this beautiful moment that you're gonna have. Many of there's a very finite number of these moments you're going to have um so you want to save for every one of them. So again, I don't think i'm alone in that. I think a lot of parents, for example, can relate to that and that's literally just one of many different things. And by the way, I wouldn't have said that that was my greatest chAllenge either, but it's something that requires, I think, deliberate attention.

What you're looting to is A A chAllenge with holding a single time perception or perception of time. One of the most remarkable things to me about the the human brain is our ability to be present or think about the past, the future or the present in the future and we can occupy different time means and then the recent um non recorded conversation of hours you showed mean something that i've seen before. But for some reason this time I had a profound impact on me, which is that you have a chart of the number of weeks that you're going to live and you mark them off one week at a time. We are talking about this in the context of major life decisions um and IT illustrates the fact that we need A A chart such a chart that we can't really move through our day being present to the the beauty of working on a lego with our kid while also paying attention in fact that well this is a week number whatever six hundred in the urb x number of weeks of one's life so that that ability to contract and dilute our time perception is is marvellous but is also a double age sort, because what takes us out of what's meaningful in the moment. One serve has to wonder then whether not our chAllenges in being present um you know I guess the psychoanalyst maybe we need to uh or psychiatrist may we ask our uh paul county um do you know I know um and respect greatly um whether not this is some um a subconscious refusal of of our own mortality or something right that if we were to really contemner mortality on a regular basis, not just when we're marking off the week of the poster, we wouldn't be able to be present because it's kind of overwhelming right?

I don't know. I mean, doesn't I I feel like the literature says that people who spend more time contemplating their own mortality are actually more at peace. Kind of a little bit of the exposure therapy idea. And so so i'm not sure it's an unhealthy thing to be aware of your mortality.

I suspect it's it's it's helpful in as much as you accept IT, right? And and you feel you have some agency over parts of IT, right? Like I don't think I have nearly enough agency over the length of my life. I think i've got five to ten years a wiggle room that I can extract if I do, if I do all of the things that i've written about in that book. I, I, I bet I can stretch my life out ten to fifteen years at the maximum call IT ten over what we've happened.

If I didn't do those things, maybe it's more but but you know that that depends on what we're comparing IT to right from being reasonable, maybe being a little bit you know, hyper functioning, maybe it's ten years, but where I know I have a much greater agency is on is inequality. And for me now a big part of that is in terms of quality of relationships. I think that's a big thing.

And I I think for most people, that's that's that's what I hope this chapter does is IT. Is IT sort of allows more people to kind of taken appraisal of that and ask that question before it's too late? Am I living my life more for my resume virtues or from my ology virtues? To borrow from h David brook's work, the road to character, which I, I, I talk about, is being kind of one of the many aha moments that I had during this journey.

yeah. And there again, thank you. You recommended the road to character to me. I do an annual solo wilderness trip, and I listen to a during the drive to that trip and on that trip and it's and I would just say it's it's a truly important book for everyone to listen to you. It's really quite, quite impressive.

What are the things that you do on a regular bit, let's say, on a daily basis to try and enforce um forgive the word but enforce emotional well being in health in terms of relationships because as you point out, it's not reflective for for everybody and that doesn't make them bad people. And I think IT does have to do with this chAllenge in balancing expectations of work and other things. And and for some people are more inherent selfishness.

And for some people, they aren't selfish enough, right? I know plenty of people running around trying to serve everybody and then their health is crashing or their mental health is crashing. So I couldn't cut any which way or always what what sorts of practices do you incorporate or just even thoughts within your own mind. You use charts and list I you're very regimented about your workouts um building grip strain uh e centric um zone to the centric training zone to its a why wouldn't we also script out the things to pay attention to each morning and day as .

a list of to do well, I have done those things right. So certainly you and I write about on the book, I gone away a couple of times, right? So I two thousand and seven I spent two weeks at a facility in kentucky in twenty twenty, I spent three weeks at a facility in a arizona um and on the back end of that facility three years ago, when I got out, I mean, I had I had a very clear list of daily things I needed to do.

And so so at that point, for about six months following getting out of that stance of rehab, I mean, I was I mean got the list of behaviors I was doing every single day. I mean, twice a day standing in front of the mirror, reading my list of affirmations, writing in my journal, every single day I had therapy every single day. I mean, all of that stuff was highly regimented.

You know, today I would say there is no one single behavior that is, quote, Mandates as part of my recovery. But perhaps the most important thing that does come up every day is um being mindful of an acting on as quickly as possible every time I um do something damaging to a relationship. So um I would say that like if you compare formula one, one of my my favorite worked by far, if you compare formula one forty years ago to formula one today, the difference is not in the number of accidents that takes place.

The difference is in the fatalities of those accidents. There are just as many, if not more accidents in formula one today. The differences nobody dies in those accidents.

The cars are so much safer. They're engineered first for safety, second for performance, used to be the reverse. And that's why there is a day when every second or third weekend a driver was killed. It's catastrophic to imagine what took place between the sixties, and about the middle is in formula one.

And similarly, I would say that the frequency with which I have in interaction with a person who matters to me, that is not the best interaction that could be, is only slightly less than what I was five years ago. The difference is the severity of that is much lower. And more importantly, and most importantly, the length of time between when I screw up and when I make a mense is infinitely shorter.

When IT went from being, I would never make commends to. If i'm addict to my wife, I usually am trying to rectify IT within a few minutes or at most a couple of hours. And and so it's it's really one thing I learned throughout this journey was if if you hold yourself up to this goal, if I have to be perfect, if you be the perfect dad, I have to be the perfect husband, have to be the perfect friend, you're going to set yourself up for failure because you, you're not going to be perfect. But if instead you can say, what i'm gonna perfect about is repairing damage when I cause IT, that's what matters.

You know, the other day um I yelled at my son for something is a while I actually because before I lost my voice so you I don't know he was just doing something and he was wrong, you know, like he was like he did something I told them one hundred and fifty times not to do and I yelled him and punished like, you know but I was way too harsh like because basically I basically the first twenty seven times he did IT I didn't respond and then when I finally did it's like, I blew a gas get right but what I realized is, yeah, I you could say, well, maybe IT hurts a child to do that. But I think IT hurts them way less if you can immediately go and repair and say, hey buddy, that he was little harsh in that i'm sorry, I didn't mean a yellow. You like that, but what you did is wrong and you're not onna get to go out and play right now as a result of IT.

But I love you very much, and I want us to do Better. I want to, I want you to do Better and not doing this thing. And I want to do Better and not yelling at you when you do this thing.

It's not rocket science, right? But I just think I used to live my life in a way where all I did was brake shit and never fix IT. So you're living in a house where everything is broken.

Where's now? I still break things, but now I clean up the mess. And oh, like, I will send the houses Better.

What is your process for when there is a need for repair but you feel that IT wasn't you IT was somebody else's error or potential error. So you can very humbly um express how you go about repairing your your errors um but what about situations where um loved one, a co worker, you feel screwed up or wrong? You right as many people do we all do from time time feel this way.

Do you approach them and try to repair the the situation because there's a little bit less or far less control when you know then the situation you described and by the way, the situation you describe that as a private one because um I think, uh, we all grew up. And so the answer to the second question, order of the answer to the first, which is if everyone did what you were doing, the world will be truly a far Better place, but not everyone's doing what you're doing. So if if you feel wrong, assuming that wrong was IT know, wasn't a sociopaths motivated, what is your process for going about repair ring, a relationship fracture like that? Again.

this assumes that this is a relationship that matters, right? So in every interaction, you you're only really able to optimize around one thing. And you have to decide as this one thing that i'm optimizing around the relationship or is that the outcome? And there are other things to optimize around, but you understand that .

those are different, right? And maybe you could elaborate on little bit.

I think I get IT, but that if the market i'm trying to buy a new car and i'm sitting their talk into the car salesman, that's a relationship. That's an interaction. Now I want to buy this car for as little as possible, and he wants to sell the car for as much as possible.

Well, in that interaction, my relationship with him means nothing left to say. I don't know this guy. He's not like my best friend. I'm optimizing everything around the outcome. So everything I do in negotiating and and interacting with him personally is based on getting the best outcome for me to very selfish, right? Nothing wrong with.

He is in the same.

But now, for example, pretend that you are the car salesmen. You're one of my closest friends and it's your dealership. Like it's your money, like it's you know, you can't sell this thing to me at a loss.

I don't want you to do that because I I want you to be able to make money. And similarly, like you care about me and you don't want me to overpay for this. So now we're negotiating and we're both trying to optimize for outcome, but there are relationship also matters, a very different negotiation at that point.

And so I think I always try to ask myself this question when i'm having some interpersonal conflict, which is what am I optimizing for? So you know if if i'm having a coral with my wife, I have to remind myself that the outcome is the objective or outcome is not necessarily the top priority. You are being right all the time, which is my defauts stake.

It's just to be a bow in a china shop is to be authoritarian instead of authority tive. And that's that doesn't work if the relationship matters. So to answer your question, the first thing i'm going to ask myself if i'm try, if I feel slighted, is what is the nature of the relationship? Is even worth trying to do something about this? And personably, you're asking the question because the lens is, yes, this is someone who you you care about more than in just a transactional way.

You know, usually what i've realized is I can't try to approach the situation without fully understanding myself, and that takes a while. So generally, and this is where you I still one to two times a week, i'm still working with a therapist. I have to kind of try to figure out on my own, and the usually bounced off a therapies and say, well, I think this is why i'm upset about this.

I think that when this person did this, her said this, I felt this first all am I? Am I correcting what I felt? Because remember, sometimes you might, at least for me, this was the case, I would just feel anger in response to every interaction.

But what I didn't realize was that anger was really just a another emotion that was superimposed on top of hurt, or superimposed on top of fear, or superimposed on top of shame, or superimposed on top of something else. But I didn't know how to articulate any of those other emotions. So the only thing I could really articulate was anger.

So if anger is the only thing I know and anger is the only response I see, it's not very helpful. It's not very insightful. So that's that's a big part of IT is being able to deconstruct what i'm feeling oh, what I really feel is loss or what I really feel is abandoned right now.

And that sometimes takes a while to figure out, at least for me. I am still you know, i'm only a few years into this journey and maybe other people figure these things out when they were there are twenty years. And so the veterans, they can do this more, more naturally. But that step one, if I don't really understand what's going on, I can't even begin to try to approach this person to say, this is how I feel, this is, you know, how do you feel and what are we optimizing for in this interaction?

I certainly know you are not alone in this sense as a process, and IT takes a lot of time and and on a case by case basis, can take a lot of time to figure out, you know exactly what one is feeling.

I think IT really goes back to the the course ness of languages in a way to sort one's feelings that was actually your other because we meet your paul coni who is one of your um stanford medical school uh classmates but uh another previous guess on this podcast who was also one of your medical school class mates um doctor called this right psychist and bioengineer phenomenal stature and doing amazing things in the world who said, you know, most of the time we have no idea how other people feel even though we think we do, and most of time we don't even know how we feel. I mean, our ability really know what we're really feeling is terrible and yet we recognize the the road, the broad bins. I'm pissed off.

I'm super happy and relaxed. I'm tired. I mean, you think about how course that uh, that languages is for that we're all the nuance and all the underlying things is conscious, conscious that could be driving in emotional state. It's really it's really quite unbelievable.

Yeah beyond the available that you know positive versus negative, that was about the extent of my emotional language until you know somewhere recently.

Well start you come a very long way. Maybe you could share with us a little bit about what you learned on these um what you called retreats or I think in in the bookshop ter you describe deliberately going off to uh a treatment center, multiple treatment centers over time to really drill into this process of understanding oneself Better and how one's current state of emotional processing and motion stability are influencing relationships in the key importance of that.

What was there any of overriding theme for you? For instance, could you trace back to specific events or themes of childhood that need a lot of IT makes sense? Um or is IT um far more nuances than that? Well, you know.

the first thing I would say is I wish I could tell you that this was a very deliberate and wonderful choice that I just decided i'm going to go on a little you self healing journey. But unfortunately that was not the case in both cases in twenty seventeen and twenty twenty um i've vert I was as close to having no choice in the matter as one can have so both of these experiences represented um total rock bottom moments in my life ah so this would have been the two lowest points in my life for different reasons but but they were nevertheless the two absolute low points in my life and I would say, you know, in the first instance I I guess I could have chosen not to go.

But I would have lost everything that mattered in my life at that point um and I had you know a good friend, paul canti, basically telling me that I needed to do this, that I really needed to do this. And in the second situation, though, completely different circumstances, you might think how can one person in just a span of three years find themselves in in a situation where they almost, without having any choice in the matter, have to go away to a place where you you're basically locked up without a phone for, you know, three weeks and you're doing twelve to thirteen hours of therapy a day? So nothing about this was, was something I wanted to do.

Nothing about. This was pleasant, I would describe. This is the most difficult things have ever done in my life, bar none. And i've done some difficulties in my life, but they have always been physically difficult. I love doing physically difficult things, but this was emotionally the equivalent of for me. You climbing k two and swiming the english channel in the same month something that just I couldn't couldn't father um so so with that said, yes, I learned a lot and I learned .

that people .

like me can be overly analytical and that that hyper analytical nature can lead you astray when you think that you're intellect is giving you a fact based explanation for a set of circumstances and you rationalized them away. Well, this happened to me when I was a kid but you know like I get IT and it's not really a problem.

And as a result of that, you know it's a it's these actually some positive things that came out of that experience and and and I think the real aha moment in my journey, which occurred um on on a day that I remember very well, was the day I finally dropped that I dropped that um that rationalization and I allowed myself to experience what a child would experience in that moment and then understood. What the implications are for a child going through these things and I think that was that was really the first time in my life I ever accepted emotionally something that I had intellect always said, ah doesn't really matter. I mean, it's know what's just life and those things happen and lots of worse things happen to lots of people and and that's OK.

And I think it's not that once I emotionally accepted this, I became a victim IT IT wasn't at all. I just finally allowed me to realize, oh, I can let that go now. I don't have to. I don't, I don't have to. I don't have to be a slave to the adaptations that came from that I can, I can, I can surrender .

some beautiful and um and inspiring to me I think that yes, there's this incredible ability that the human brain has to script the story and to compare at other people circumstances and said rationalized what essentially emotional traumas of water, physical traumas um from the perspective of the adult but um if I know one thing for sure and make IT very clear, i'm not a clinic, but is that the brain doesn't um discarded of any circuitry we we purpose the same circuitry we used as children as as adults and so the ability to go back to that into and to part IT but as as you point out, not from a from an intellectual standard standpoint but from an emotional standpoint, seems to be that the really hard work do you do that on a regular basis?

No, not not at all. It's been done a handful of times. Um it's been exhAusting. It's it's very difficult.

It's it's don't know this is the right where I would almost describe IT as emotionally violent and it's it's it's not something I need to revisit often truthfully, I think that yeah it's it's been done a finite number of times and I think i've captured so much so much value from IT that there are lots of other things I continue to do I mean, you know I I use a system called dialectical behavioral therapy that is a regular part of a therapy that I do um but I don't have to go back to my childhood. Don't have to go back to uncovering and and we expLoring a lot of that stuff. I've i've learned the lessons and now it's really about practicing the skills.

I know I know what I want now and and I know you know you talk about plastics. I'll share one example, which I know I wrote about in the book, but but just for folks listening that you will appreciate. So I you know just one of the one of the hallMarks of my existence has always been, you know, just A A an insane amount of anger and rage.

It's it's been there as long as i've known so I don't have a conscious memory of not having rage, right? So earliest memories of life when i'm five years old, I have rage like you can't believe and it's it's a problem all my life. So is a teenager if I go more than two weeks without punching a hole in the wall of our house, it's a miracle.

I mean, I am so good at dry wall. You can't believe how good I am for all the stuff I have to repair around our house. Like i'm breaking windows. I'm breaking IT just doesn't like I just and so in my way, and of course, I rationalized how much boxing saved my life because I had this amazing outlet for my rage, right? If you got to basically exercise six hours a day hitting punching bags and people all day long, and it's just a beautiful outlet that keeps me out of jail.

Um and a big part of that rage was inward, right? So it's it's not rocket science to understand that a person who has that much hatred for everyone has an enormous amount for themselves. And so one of the things I didn't realize was happening was what my inner monologue was because you can appreciate your inner monologue is so frequent and ubiquitous, ous and present that is easy to almost forget that it's there.

I mean, that's the that's that's the sort of, uh, dangerous part about IT, right, is kind of the David Foster walls. This is water thing. The fish are selling through water IT.

The water is everywhere and even realize there in water you don't unrealized, don't realize the subconscious stream of thoughts that constantly flow. But eventually I became aware of just what that self talk was, and IT is. IT was no longer the case. IT was the angriest, the most violent self talk you can imagine. I mean, IT was like, there is no mistake that I could make that was anything other than my perfect, perfect standard that didn't result in what I would call my inner Bobby night going ballistic.

So IT just didn't matter, like, sounds silly under IT didn't matter if I didn't perfectly cook a stake, if I didn't perfectly nail something I was doing, if I didn't do anything that was perfect at what I described as match grade perfect. I mean, I would want to beat myself to a pop and I would stream at myself. I mean, it's just it's it's again, it's hard to describe.

And I I hope that most people listening to this don't understand what that feels like. Well, IT became very clear that that had to change because when you were when you are that when you hate yourself that much, by definition, you are going to be an insufferable c to everybody else like because you're you're just that's onna spill into how you interact with the world. So I, you know, was working with a therapist who was one of the people who was sending me to this place in arizona.

And basically, IT became clear that they proposed that I could shed this trade if I was willing to do certain amount of work. And I was like, there's no chance. Like i'm forty seven years old.

This is the only way i've ever interacted myself. How in the world could this be on done? You'll take another forty years to undo this. And they're like, no, no, here's this exercise. You're gonna.

So the exercise was, every single time I did something where I would have that self talk, I would have to immediately stop myself and pretend that IT wasn't me that just did that, but IT was one of my closest friends. And instead I would oddball speak to that person. There is nobody else there, but speak to that person as though they are the one that made the mistake.

And I was, I was to record that on my phone. So if i'm not there, shoot my bow and arrow and I don't get a bull's eye. Instead of screaming at myself, I have to say, oh, imagine my buddy J.

R, who just missed that shot. What would I say to him? Pick up the phone or pull up the phone and say, of course, something different.

And of course, what I would say in that situation was much kinder mean, infinitely kinder. Like from saying IT to my closest friend, I say, in a very kind way. And I had to take, uh, a copy of that audio and text IT to my h wow.

yeah. Talk about image. I was all on board this practice until you mention that at which point, and and I trust my therapies to very deep level. But I thought, wow, that's a, that's a mountain. Well, this, you know.

this is poor person got a lot of text messages, lot, a lot of audio files. But here's the part that just blows my mind IT only took, I don't know, I can't remember exactly. I have to go back to look at my journals and took about four months to get rid of bobbi night. Like, you know, again, we we had kind of a mental model for what this looked like, which was, bobbi night was the chairman of the board. He SAT in the board room, and nobody else got to talk.

And for those who don't know, bobbi night had a terrible temper. yes. Yeah, the worst. right?

This is the guy that was thrown and .

chairs across the basketball court level .

eleven out of ten and and all of a sudden, like we got to the point where Bobby night is not even in the board room anymore. In fact, I as I say this today, like I don't really remember what he sounded like and it's amazing to me and and i've had some really amazing opportunities to bring him back. Like it's not like i'm making fewer mistakes, right? It's not like i'm Better today than I was three years ago at all.

The things that I do, i'm not i'm actually probably worse in many regards, but the difference is I can communicate with myself. I I think I can say this. I think I can say lovingly, right, and and maybe not as lovingly as some people can.

I still think i'm probably maybe just a little higher standard with myself, then maybe I need to be at times. But but i'm just not beating myself up like I used to. And I think by extension, i'm beating other people up a lot less.

Well, I don't know the extent to which your internal narrative reflects the narrative that others have about you. But first, so I want to thank you for sharing what you just shared, I think, as a practical step IT first, while to one i've never heard of before, but certainly represents this incredible phenomenon of neuroplasticity, because four months sounds like a bit of time, and yet you were forty seven years, forty seven years of a IT.

Just absolutely bring self talk is what that sounds like. So it's something that people can can think about for their own, for their own purposes and their own chAllenges. Also, i've read the book twice now and and love IT as as as I put in my endorsement of IT.

I think it's not just informative, but it's indeed important because IT centers on so many of the key actionable items related to the health, spin and lifespan, vitality, lunch, evi, whatever people want to call things that are essential but also this the section on emotional health that was absolutely profound for me and inspired a huge number of changes um and the book as a whole represented a very important contribution to everybody there. Numerous points, and I would say every chapter is applicable to everybody. There are very few books out there like that.

Um so I want to thank you for that and especially for including the section on emotional health and especially for and sharing what you did today because I think IT doesn't just take a bit of vulnerability, but at a ton of vulnerability and humility to be able to share what you just shared. And my only request or wish is that you also hopefully internalized the tremendous gift that you're giving everybody through coming on podcast like this, doing your own podcast, writing the book. Now I look out on the landscape of front facing, public facing health out there, and you sit not alone, but in a unique stance as the the medical doctor that I do believe that people trust the very most because of the fact that you have the intense rigor.

You I wouldn't say your desire, your. Absolute obsession with measurement and and precision um many of the things that a moment ago you were pointing is as potentially you know hazard for your emotional life but that serve all of us the general public um so preciously and so with a just in culpable value so I hope that journalizing as well maybe it'll leaving we've into yourself thought maybe I D need to send you a script every day but in all series is I also want to thank you for taking the time today. And um even though it's a personal thing, I really want to thank you for your um being an amazing colleague to me in the podcast space, in the in the health and medicine space, whatever that is and also um just seen in an incredible friend, you've been a tremendous source of support and guidance in every one of the domains that we talked about today and many more.

And again, I just want to say that this emotional health component, I agree with you, I think it's it's not just vital. I think it's it's the the most divine al of all of them. So you've just made .

numerous important contributions.

and I just want to thank you for sharing. You clearly put everything you have into everything you do. Thank you, Peter.

and thank you. Thank I really appreciate you making the time for us to sit down and talk in a long form way which I enjoy um yeah it's it's it's an it's an honor and that means a lot to me that you have have read IT twice and that you've appreciated IT in the and praised praise that as you have. Thank you.

Thank you once again for join me for today's discussion with doctor Peter a tea. I hope you learned as much and enjoy the conversation as much as I did. Please also check out doctor T A new book which is releasing on march twenty eight, twenty twenty three, entitled to outlive the science and art of longevity.

If you're learning from end or enjoying this podd cast, please subscribe to our youtube channel. That's a terrific zero way to support us. In addition, police have ripped to the podcast on both apple and spotify. And on both apple and spotify, you can also leave us up to a five star review.

If you have questions for us or comments about the podcast or topics you'd like me to cover or guess that you'd like me to include on the human podcast, please put those in the comment section on youtube. I do read all the comments. In addition, please check out the sponsors mentioned at the beginning and throughout today's episode.

That's the best way to support this podcast. On various episode to the human man lab podcast, we discuss supplements. While supplements aren't necessary for everybody, many people derive tremendous benefit from them for things like improving sleep, supporting hormones, improving focus and so on. The huberman la podcasts is proud to a partner with momentous ous supplements. If you d like to see the supplements discussed on the here room in lab podcast, you can go to live momentous spelled O U S live moment is dot com slash huberman if you're not already followed ing me on social media, it's huberman lab on instagram, twitter, facebook and linton and at all of those places I cover science and science space tools, some of which overlap with the contents of the huberman lab podcast, but much of which is distinct from the content covered on the huberman in lab podcast. Again, it's huberman in lab on all social media platforms.

If you haven't subscribed to the human lab, pocket neural network news letter is a monthly newsletter that includes free tool kits, things like tool kit for sleep, I enhance the quality duration of your sleep, tool kit for focus, tool kit for neuroplasticity, tool kit for delivered cold exposure, heat exposure and some maries of podcast episodes. All of those tool kids can be found by going to huberman lab dot com, go to the menu screwed down to newsletter, and simply give us your email. We do not share your email with anybody.

And again, the newsletters and tour kids are completely zero cost. And you will also find some PDF examples of previous tool kits, again, that huberman in lab dot com. Thank you once again for joining me for today's discussion with dr.

R. R. Peter a. And last but certainly not least, thank you for your interesting science.