Dr. Peter Attia - The Portfolio to Live Longer - [Invest Like the Best, EP.325]

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0:25 Operate smarter and stay ahead of the curve. See what Ridgeline can unlock for your firm. Schedule a demo at ridgeline.ai. Hello and welcome everyone. I'm Patrick O'Shaughnessy and this is Invest Like the Best. This show is an open ended exploration of markets, ideas, stories, and strategies that will help you better invest both your time and your money. Invest Like the Best is part of the Colossus family of podcasts, and you can access all our podcasts, including edited transcripts, show notes, and other resources to keep learning at joincolossis.com.

1:00 Patrick O'Shaughnessy is the CEO and founding partner of Positive Sum and the CEO of O'Shaughnessy Asset Management. All opinions expressed by Patrick and podcast guests are solely their own opinions and do not reflect the opinion of Positive Sum or O'Shaughnessy Asset Management. This podcast is for informational purposes only and should not be relied upon as a basis for investment decisions. Clients of Positive Sum or O'Shaughnessy Asset Management may maintain positions in the securities in this podcast. My guest this week is Doctor Peter Atia.

1:35 I've had Peter on the show twice before, but it's been more than five years since his last appearance. In that period, his work has exploded, and today he's one of the clear leaders on the topic and practice of longevity and health span. He has a new book out called Outlive, which I heartily recommend. You'll hear us refer to the last chapter of his book early in our conversation, but we chose not to reveal the whole story live so you can read and enjoy it. Also, if you want more of the nitty gritty tactical stuff from Peter, I highly recommend his recent podcast episode with Tim Ferris.

2:05 In our conversation, we highlight the big picture, including the transition. from medicine two point zero to medicine three point oh. I always leave these conversations with Peter full of ideas and in this case highly motivated to go outside and move my body in nature. I can think of no better actionable advice. Please enjoy my conversation with Peter Atia. Um

2:27 Peter, I've been so excited to do this with you. If you can believe it, both of the prior times we've done this were actually in person, which means they were both pre-COVID. Which is kind of a gnarly thing to imagine how much time has passed. But it's so nice to see you again. I so enjoyed your book that came out a few weeks ago. I think it's one of these books that will still be read in ten years and teaching people about health and longevity and how to live. As I thought about framing our conversation, a mantra that my friend Sam Hinke shared with me keeps coming to my mind. And I think it might make for interesting architecture for our discussion.

2:58 So the mantra is strong body. Calm mind. House full of love. And I would love to take that outline with you in discussing all that you've learned.

3:08 But before we get into strong body. I'd love to just understand how you personally have changed. In the process of writing this book. I know it was an ordeal. You restarted it a number of times. You worked incredibly hard on it over a period of years. What did the process of writing the book do to change you most?

3:25 Great question. Before I answer it though, I do want to give A shout out to you, Patrick, because You are definitely one of Probably three people that had the greatest impact on me starting a podcast.

3:38 So both times that you interviewed me and I sat down with you were not only pre Covid, they must have been pre two thousand eighteen. They were, yeah. Yeah, I started that podcast in Two thousand eighteen, almost exactly five years ago. And I remember both times very well that we sat down together and You constantly said, Peter, you really should be doing a podcast. And I had a hundred reasons for not doing it.

4:01 And I don't know why on the nth time of your nudging, I said, Okay, you know what, Patrick, introduce me to the guy, Matthew Patsy, who is your producer and does your podcast and I'll at least entertain the idea and of course Yeah, here we are five years later, still working with Matthew Thanks to your introduction. So it's actually not clear to me I would be doing a podcast. Were it not for you.

4:22 And I can tell you then from a process perspective, this book would be a fraction of what it Is. If not for the podcast. In other words, the podcast is Basically the vehicle that is a forcing function.

4:35 for my learning. Yeah, amen. The poop could suck if it weren't for the podcast. Very cool. That's awesome to hear. Okay. So your question was how have I changed

4:44 I think greatly. And part of that is just I think the natural evolution of change that would have occurred if I wasn't writing a book. But I think what the book does And what writing does in general, whether it's blogging or doing something as involved as writing a book is it forces you At least it forces me. To be a better thinker.

5:03 And I think that's probably true for most people who write. I never thought of myself as a writer. And growing up was More the math science guy. But when I did start blogging in two thousand eleven

5:15 I immediately fell in love with it. because it became another expression of thought. And I always wanted to think of a better way to explain something. And doing it in words.

5:27 requires more precision than doing what we're doing right now. You could tell right now I'm wasting time, wasting words and things. You Can't do this when you write. So that's the first thing. It just made me a better thinker. And it made me go back. And

5:41 Imagine More accurate, articulate, interesting. orthogonal ways. to explain difficult concepts.

5:51 And Create frameworks. I've always gravitated towards frameworks. But I think it became more important as the complexity of the subject matter Evolved.

6:00 There's a really deep and personal reason. or way in which I think I changed through this book, which was And I kind of allude to this a little bit in the epilogue. There was always an uneasiness. and a tension I felt in writing this book.

6:16 which is captured in the last chapter. And then again I think Synthesized through the epilogue, which is There was always a little bit of a feeling of hypocrisy, which was Well, you're really focused on this living longer thing, but you're really failing in the living better thing. In particular through

6:35 The happiness, emotional health, connectivity. Side of things. And I do think that a lot of the fits and starts that I experienced in two thousand seventeen, eighteen, nineteen.

6:48 were As a result of that. internal conflict. And so in in some ways Finally getting to the point where

6:56 I could write the book and finish the book. Required. coming to peace with addressing some of those issues, if that makes sense. It does. the last chapter of the book is incredibly powerful. And I think those that read it and have read it

7:11 Would agree. It's probably the best chapter, even if it's maybe the most Unexpected. What was the process of that resolution because It's very easy to say like I went on a big journey. I learned a lot and I'm coming back with, you know, sort of the classic hero's journey architecture, like I'm coming back with new truths with the grail. You know, I went into the belly of beast and I got the grail and here it is. I came back with it.

7:32 And what people gloss over is what hell that belly of the piece can be. And so what was that process like for you? Penny backing off that final chapter. coming to that resolution. So powerful.

7:44 Well Depends, right. I think the belly of the beast part was horrible as you describe it and It is interesting, right, the hero's journey. It's a bit of a cliche, but it's a cliche for a reason. I think most people who have gone through

7:56 Something. That is defining for them. We'll relay some elements of that story. While I'm going through it, of course I'm not thinking about anything other than

8:06 the anguish or the Shame or the guilt or the pain of it. But it's interesting how when I emerged from it. I finally Felt ready.

8:17 To right. And That was something I couldn't have done before. Right about that. Right about that topic. And

8:26 I didn't feel ashamed anymore and I didn't feel like I was a fraud. This was Probably the single biggest thing. We talk a lot about imposter syndrome, and I think a lot of people feel it. If there was an impostor syndrome Olympics

8:42 I could have been the Michael Phelps of it. It made me so sick if anybody Praised me. It made me so sick if anybody Said

8:53 Great job. It was very weird. I mean it was weird even having my medical practice where People would I had this awful feeling, which I'm sure many people can relate to, which is

9:08 Oh my God, I hope they don't find out how much I don't know. And I was You know, I don't want to say crippled by or paralyzed by, but perilously close to that. for a very long time until I wasn't.

9:21 And Emerging from that is what really allowed me to finish the book. If you really think you're a fraud

9:29 I don't know how you can write. I don't know how you can Produce anything. Certainly something that's non fiction. Maybe if it's fiction it's easier to say this isn't really about me, but But if you're writing something

9:40 that is supposed to be your best representation of the truth. And you think you're not worthy of writing anything because you don't know anything. That state of conflict is so great. I don't know how you can do it. So That might have been the single most important step. In

9:57 getting to that final home stretch in twenty twenty, which is what happened by late twenty twenty, to get to the point where you know, this book was basically then Completed in relatively short order. I want to ask one more question there because It's almost like alarming to me if I think back on our original conversations and then when I read the book. What you're describing in the final chapter actually happened after our conversations. And if I think back on the especially the first one.

10:21 on your point about imposter syndrome, like I would have been one of the people that said, like oh you want to know about this. This is your guy. This is the Not the Michael Phelps of imposter syndrome, this is the Michael Phelps of longevity research and health span and introducing these concepts into the lexicon. And so it's like very disarming to me. That What then happened

10:39 As you describe in the book. happened after that. And I would love to understand if you were really feeling those things. What caused the phange from feeling like a fraud to not

10:51 feeling like a fraud or from impostor syndrome to not imposture syndrome like What was that phase transition? And what precipitated it? Well, those are two different things. I think what precipitated the change is what precipitated the work. And what precipitated that was out of my control in the sense that it was

11:11 Kind of hitting At least a local minima, if not an absolute minima. So the stuff I write about in that chapter, which I you know, I won't give it away in case folks are still gonna go ahead and read it, but the personal crises that emerged.

11:23 That effectively left me with very, very hard choices, none of which were good. It just left me with a series of Awful choices. in my personal life. And fortunately

11:37 I chose What was very difficult, but was clearly the best choice, which was confronting All of the underlying beliefs. And going away. I mean it meant going as I right about going into

11:49 inpatient residential care for a long period of time on two occasions. And doing the hard work that addresses the underlying belief system, which is really the point that you're getting at, which is how do you do that? Boy, I hate to talk about something for which I have so little

12:06 knowledge other than my own personal experience. This is one of the challenges of this subject matter is if you're asking me about heart disease and cancer and Alzheimer's disease I don't have to speak about them from my experience. I can speak about them With expertise. having read the literature in a science where

12:22 It's not that ambiguous. Some things are, but a lot of it's not. Talking about this stuff, it's much more experiential. And I think that

12:31 We all have a set of beliefs. About ourselves. Some of those are healthy, some of those are not. But We

12:38 Tend to for various reasons. I think find ourselves at times in places where those beliefs are Much more unhealthy than healthy.

12:48 Or more complex where some of the beliefs produce good outcomes. They produce hard work. The insecurity can produce hard work. The hard work can produce external validation. But on the inside they're rotting you and the hard work is coming from a bad place, not a good place. So think of this.

13:06 You can think of two athletes who are performing equally well. On the outside. You look at them and you think, Boy, they both look great. One of them is doing it from a place of love. Just loves the sport, loves the practice, loves the process, loves the journey.

13:23 The other one is doing it purely from a standpoint of punishing themselves. We see this a lot in endurance sports, by the way. Just Every workout is an opportunity to punish themselves more.

13:36 They might both end up with the same results. They have a totally different internal milieu. And you wouldn't necessarily appreciate that from the outside. Yeah, it seems like the unhealthy one of those athletes has this highly revved frenetic Internal state.

13:50 Whereas the one doing it from love is sort of the opposite state. Does that describe your own switch, would you say, like from a state of being over revved or hyper revved to one of being Calmer.

14:02 Yes, for sure. And I even mentioned that I think in the epilogue, which is my quest for longevity. was such A Frenetic. Race

14:14 Two Avoid death. because of my fear Of not being here. Not my fear of the mechanics of dying.

14:24 But their real fear of running out of time before I could fix the problem that deep down I knew I had. But wasn't willing to fix. So it was how do I just

14:37 buy more time, buy more time, buy more time to fix this thing I know I need to fix, but I'm never gonna fix, but I'm gonna kick the can down the road indefinitely. And that's why I'm Pursuing this thing. Holy shit. Such an interesting Beautiful insight.

14:51 I would love to dive now into some of the incredible Bindings and discussion and frameworks in the book And I think to do that before we get to strong body as a big important thing to talk about. I was amazed by how much this book was really an ode to working out and being physically active.

15:07 Which is good'cause we can all do that. I'd love you to describe this Framework of slow versus fast death. And medicine two point oh versus medicine three point oh and how those two frameworks interrelate, I do think they govern a lot of what we'll talk about.

15:22 Before medicine two point oh, obviously there was something that I'm calling medicine one point oh, and that was basically all of human history until the late nineteenth century. And We didn't really Have a sense of what was going on. We didn't understand

15:39 the natural laws of the universe. We didn't have a scientific method or any of these things that we just take for granted today. And fast death was the norm. So fast death was primarily that of infections, communicable diseases, and trauma. That's how people died. That's how we died. for millennia.

15:59 And our life expectancy was relatively short, probably on the order of thirty to forty years. And look, that was good enough for us to reproduce and evolution and natural selection did a lot of stuff during that period of time, though they moved at a glacial pace. And again.

16:15 Fast death ruled the land. But somewhere between the late seventeenth century and the late nineteenth century, over about a two hundred and fifty year period of time. things began to change. And that sounds like a long period of time, but again in evolutionary time that's a relatively short Blink of an eye.

16:32 And basically You had a new way of thinking. Which was these ideas proposed by Francis Bacon around the scientific method and this idea that you could make observations And you could form hypotheses or take guesses about what was causing those observations.

16:49 in nature and you could design experiments. to test those things and compare the results. of those experiments to your predictions to then confirm how accurate the prediction was. This was so foreign. You could think of this on par with

17:05 The development. Of The internet. Or the development of the airplane or the automobile or

17:12 Electricity. I mean it was that fundamental An insight. Didn't translate into a tangible thing like an airplane is or like electricity is where you see the light. But it

17:24 arguably had at least as much impact. And in fact you wouldn't have those other things were it not for that insight. Of course, it would be another couple hundred years until another very important technology came along in the form of the microscope. That would allow scientists and physicians of that era to actually begin to see things that were previously invisible, namely bacteria and yeast.

17:47 And Of course, finally you had the development of tools to treat These microbes in the form of antibiotics and ultimately vaccines. And therefore in a span of a really Evolutionarily speaking, short period of time.

18:03 we leapfrog from medicine one point oh to medicine two point oh. And we effectively get rid of fast death. In the span of a couple generations, we double human lifespan. By

18:18 getting rid of infectious diseases. And when I say getting rid of, I just mean reducing their mortality so much so that all of a sudden an infection doesn't mean the end of your life, trauma doesn't mean the end of your life necessarily. And Now we're left with kind of a new problem.

18:36 And the new problem is Oh. We do live longer now, but we've got a new set of deaths, and these are called slow deaths. And these are the chronic diseases that virtually everybody listening to us talk today.

18:48 Is thinking about. Most people today. If they were to imagine what's going to kill them. They're not thinking pneumonia. They're not thinking

18:58 a staph infection, they're not thinking a urinary tract infection. Those things can still kill you, make no mistake about it, but they're so far down the list now. That what dominates Death. Is Cardiovascular disease.

19:10 Cerebrovascular disease, cancer. Neurodegenerative disease. These are the things that are gonna kill people slowly. So nobody dies of those things quickly. Even a person who has a sudden heart attack and dies. disease was taking place for

19:24 thirty or forty years prior. So medicine two point oh Was And remains an amazing tool. or paradigm for how we deal with fast death.

19:37 The problem is it has not been very successful. At treating slow death. And Its strategy Has been

19:46 The way you treat slow death is the way you treat fast death. The way you treat fast death is you intervene when the disease is visible. We don't go around treating people prophylactically for infections. I mean, I guess you could say we do that with vaccines. But

20:01 We don't go around treating people for car accidents before they have them. We wait until they have a car accident and then we treat them. And so When you try to apply that approach to diseases of Slow death.

20:13 It doesn't seem to work that well. we ought to be doing more of the vaccine thing, which is a preventative thing. We're not. Instead what we're doing is we're saying, look Once you have diabetes. We're gonna have to do X, Y, and Z. Once you've had a heart attack or once you have significant risk factors for a heart attack that make it likely that you're gonna have a heart attack in the next ten years.

20:33 We really need to get serious about this. Once you have cancer. We're gonna do this operation, we're gonna use this amount of radiation, we're gonna use this type of chemo. And those things have had some effect. I don't want to suggest that they haven't. But the effect has been relatively small. So small, in fact, that if you

20:50 look at life expectancy in the late nineteenth century and compare it to today. Well The nominal change has been a doubling. If you subtract out the causes of death from the top eight infectious and communicable diseases, it's been almost flat.

21:06 It's a sobering statistic. I mean it's actually one of the few this book has maybe fifteen or sixteen figures in it. That's one of the figures is just the data that show that analysis. I will tell you, I was very skeptical of those data. I was like, That can't be right. We cannot have been that impotent over the last hundred and fifty years. And in reality, it's about a five to ten percent improvement we've had. absent that major change. So indeed it is the case that we aren't really

21:33 Moving the needle much. On Slow death. And I suspect it's because The name of the game.

21:40 And this is demonstrated by the centenarians who get a whole chapter in the book. The name of the game is Living Longer Without Chronic Disease not Living longer with chronic disease. If you think about the source of that problem. And you could break it down into something like detection and treatment.

21:57 Is it more of a detection problem? Like it seems like when we identify something. the whole attitude of medicine two point oh is if you can give me something to work with. We're pretty good at finding solutions. And that these slow death things. We just don't do a lot to screen for things.

22:11 I'm pretty neurotic about this stuff. I get blood work all the time and just because of knowing you and your process, like I know that I'm not getting Anywhere near what's available in terms of like early detection for These four horsemen of the slow death. Is that the problem? Like is medicine three point oh fundamentally about

22:29 better early detection of the initial signs of one of these major ways of eventually killing us and sort of forcing lifestyle changes earlier. I think that's part of it. It's also partly a mindset change. And here I think there is kind of a a loose analogy with the transition from medicine one point oh to two point oh. It required

22:49 A different mindset. It required different technologies and it required different tools or drugs in the case of antibiotics and vaccines. So similarly here I think First and foremost, the mindset is key. If you want to transition from two point oh to three point oh

23:06 You have to accept the fact. But lifetime risk. And treating causal risk factors. is the most important Philosophical difference.

23:16 What do I mean by that? Well the model today for treating cardiovascular disease is Okay, we treat everybody for secondary prevention. Secondary prevention means you've already had a heart attack or a stroke. Is there anybody who thinks we shouldn't be aggressively treating those people to prevent

23:32 The second one, the fatal one? No. Okay, we all agree with that. The real rub comes in what we think about for primary prevention. How do you treat a person Who has not yet had a heart attack or stroke. And The mainstream view on that

23:46 Is Well, we use models that predict risk. We have decent actuary models that predict risk based on lipids smoking history, blood pressure, family history, et cetera. And We wait until there's a threshold that's crossed.

23:59 To begin treating. So In the cardiovascular literature, it's typically viewed as about a five percent ten year risk for a major adverse cardiac event. So

24:11 If I plug your numbers in, Patrick, and your tenure risk comes back at three percent, it is not deemed necessary to put any treatment Preventive protocols in place. I think that's fundamentally wrong. I've used this example in the book. It's so

24:29 hard to understand how we feel that way. in some cases, whereas we clearly don't feel that in some cases. So one example where we don't act that way is with smoking. So we know that smoking is causally related. to lung cancer.

24:43 There's no ambiguity about this. that smokers are ten times more likely on average to get lung cancer than non smokers. Which of course doesn't mean All smokers get lung cancer and not all lung cancer patients were smokers. 15% of people with lung cancer never smoked, and many smokers don't go on to get lung cancer, but nevertheless that hazard ratio is still ten.

25:04 Which is enormous. Very few things in biology produce a hazard ratio of ten. So We know that smoking is causally related to lung cancer. The implication of that is We tell people not to smoke.

25:18 Period. Not to start smoking. And if they do smoke. We tell them to stop immediately, not waiting until their risk of lung cancer.

25:26 is high or waiting until they develop a small lung cancer and then telling them, Okay, now it's time to stop. So we clearly have it dialed in. In that area. And yet when it comes to Managing diabetes or cardiovascular disease or other forms of cancer. that are not related to smoking or that have other risk factors.

25:43 We completely fail. In that same. Line of thinking. We don't treat the causal agents and we don't take an aggressive enough lifetime risk posture. Can you say a bit about

25:55 What I'll call the cross compounding. effect of thinking about all of these things together. So it's not just I've got the one thing I think about, which is heart disease because the men in my family died young or something like this, but rather you're thinking holistically about Okay, we know kind of the major slow death things that hurt us. And the impact of

26:14 compounding and reducing risks, even if those risks are small. Yeah, there were some things Where Do it. really specific risk factors that play into a given disease.

26:26 And Lots of people have done these types of analyses. Where the suggestion is that look, even if you eliminated cancer If you just Said, look, imagine nobody will die of cancer.

26:38 How much does that extend human lifespan? Someone's done that analysis and they claim the answer's like three or four years. Say, Well, that's not that impressive. Okay, well. What about heart disease? If you could just eliminate heart disease and nobody could ever die of heart disease.

26:51 What's the answer? And it's an equally kind of unimpressive answer. Those analyses are flawed in my opinion, because what they ignore is exactly what you're talking about, which is the interrelationship of these diseases. And so in the book I talk about these four horsemen of death. And They're loosely the diseases that kill us, but if you

27:13 read the fine print, you'll realize that We're mostly just dying from three of the horsemen. Directly. But the fourth horseman is probably the one that has the biggest overall effect.

27:24 Even though it doesn't show up on the death certificate as the cause of death. It's the gasoline that's being poured on the fire of the other three. So the three are cardiovascular and cerebrovascular disease at number one leading cause of death, cancer. Number two.

27:39 And neurodegenerative. disease number three, at least in a non smoking population. 'Cause I'm stripping out C O P D chronic obstructive pulmonary disease. But the fourth one Is kind of a

27:51 Category I've created. From a disease such as type two diabetes at one end of the spectrum, but also all the things that or leading up to that. So insulin resistance, hyperinsulinemia, nonalcoholic fatty liver disease. which progresses to non alcoholic steatohepatitis.

28:08 all the way to type two diabetes. Again If you added up all the death certificates in the country and said, How many times does insulin resistance appear on it, the answer is never. No cause of death is insulin resistance. NAFL D is not a cause of death. you're not gonna die from NAFL D, but if it progresses to Nash and cirrhosis you'll die.

28:26 Very few people are dying directly as a consequence. Of type two diabetes. Does show up on the death certificate. I should know those numbers, but they're not that big. But if you have type two diabetes. Your risk of

28:40 Heart disease, cancer, and Alzheimer's disease is approximately two X. That of someone who does not. So here's where you have to be able to say, I'm not just going to play whack-a-mole with these diseases. The answer is not just do infinite cancer screening and reduce your risk of cancer or

28:57 we're just going to treat lipid risk factors and eliminate cardiovascular disease. No. The answer is You have to do all of the above. Including addressing metabolic health. And this is where they're really unsexy, not terribly interesting.

29:11 word that I hate lifestyle modification comes in. Because We don't really have amazing drugs. to do that, the way we have drugs to zap lipids or treat hypertension, which, by the way, can also be impacted by those metabolic factors. But

29:27 This is why exercise Nutrition. Sleep. Stress management. Again.

29:33 They have the reputation for being so uninteresting because it's like yeah, yeah, yeah, I know that, I know that, I know that, but it's like no A do you understand? how much power those things have and B, do you understand how to dose them? This is the thing, right? I mean every doctor knows exercise is important. We are not trained in what that looks like.

29:51 We don't know what advice to give a person. And the same is true with nutrition. They don't really know what to tell people. We certainly don't know what to tell people. How to sleep better beyond If you're having trouble sleeping, here's a suite of medications that can help. Yeah. Yeah.

30:06 You said mindset earlier, and I when I was reading, I didn't think about it. in those terms, but now it's very clear that That is central and incredibly important from doctors and researchers all the way down to The mass populace. I wanna understand what

30:20 could cause this mindset shift because strong body and this idea of exercise. It's just so incredibly powerful as a We think about drugs that could affect our longevity, it seems like a lot of exercise of a certain type is probably the single best drug that exists.

30:36 But it's not the easy pop the pill thing that Medicine two point oh mindset has I guess trained us. As a species to think Oh, if there's a major problem.

30:47 Pop a pill and it gets better. So Are you hopeful about this mindset shift? What can cause this? Because if that's the answer. Which is, as you say, kind of unsexy as an answer, but still powerful.

30:59 Then we need to implement it. And it just seems like people are unwilling to Work out as much or eat better or sleep better. These aren't the pills people want. It's a very good question and I don't know the answer. So there are a few components that are embedded within that. The first is Is the transition to medicine three point oh?

31:16 Is it necessarily going to have to be driven by healthcare as the system. Or can it be consumer driven or patient driven? So My hypothesis

31:28 Which I'm happy to be Wrong on the is that I actually don't think medicine has to lead the way, I think it can get dragged along the way. In other words.

31:39 I think enough people can just say, I'm going to take charge of this. I'm going to be in charge of my own healthcare. I'm going to be in charge of my medicine three point oh approach and My doctor will come along for the ride. There are five things that I talk about as the areas that we have agency over in terms of how we impact our

31:59 health span and lifespan, nutrition. Exercise, sleep. pharmacology, including supplements, drugs, et cetera, hormones. And all the tools around emotional health. And this book doesn't really go into much depth on one of those, which is the drug one.

32:14 And part of the reason for that is That's the purview of medicine two point oh. It would take too long to write a whole dissertation on that. And I wanted to focus on the four other buckets, which are the things that people don't need a doctor for.

32:28 So if you think about it. If you assume that each of those is responsible for roughly one fifth of the output and it's not, clearly it's not. Exercise is actually disproportionately responsible for benefit. So conservatively eighty percent of what can impact the length and quality of your life, you don't need a doctor for. It's interesting that twenty percent of that equation is all we learned in medical school.

32:52 And beyond. So When you encounter a doctor. Who has insight beyond Eat less and exercise more.

33:01 And there are lots of doctors that do have insights beyond that. You have to understand that those insights came to them through their own education and their own process of learning outside of what they learned in medical school or residency. Because There is nothing we learned in residency.

33:16 that taught us anything about how to provide instruction for patients. You know, I use a a sort of glib example you may recall in the book, which is Knowing that a patient with cancer. needs chemotherapy. Is irrelevant.

33:29 person on the street knows that. You don't have to be a medical oncologist. with metastatic breast cancer by telling her she needs chemo. You need to know what her receptor status is. Which chemo?

33:43 What was the histology of her breast cancer besides even the receptors. How many lymph nodes were positive? How would you dose it? How would you stage it? How would you cycle it? All of these different things. That's where a medical oncologist comes in. Similarly,

33:56 There's no insight in saying you need to exercise more. Or The C D C recommends that you do Three hours of vigorous to moderate activity. per week. Yes. So what? That's not specific enough. It's not helpful enough. People need

34:10 I think more insight. And I don't think they have to wait for their doctors to give it to them. Look, that's part of why the book is written. It's part of why I have my podcast and stuff is I wanna make sure that people can get the most powerful tools without having to wait for their doctors to provide them that insight. How do we know that when you consider those five

34:29 Things that Exercise is so disproportionately impactful. on the outcome. Well I'll take one of them out because One of them I think can't be quantified and I think for certain individuals may have a greater impact. And I might be one of those individuals, by the way, which is all the tools around mental health and emotional health. So

34:49 That could almost be kind of a binary switch where Without that one being in order, none of the other stuff matters. becomes the problem of Doesn't matter how long you're gonna live and how healthy you are physically, if your emotional life is in turmoil.

35:03 Who cares? So let's take that one off the table and then just say if we talk about sleep Nutrition, exercise. Pharmacology. We don't have and we will never have

35:15 high enough quality randomized experiments to test head to head all of these interventions. So instead what we can do is we can look at deficiencies in each of these things. and ask the question, what are the hazard ratios associated with those things. And we can also do that by combining Other than Problems.

35:36 And I'll just Explain what a hazard ratio is,'cause I've already used that terminology. Hazard ratio Is the product of a statistical analysis

35:46 That I won't get into in great detail because it's actually complicated calculus using something called a Cox proportional hazard. Where you try to estimate what the Risk.

35:57 is of a certain variable or behavior. to an outcome. So for the purpose of this discussion I'm going to talk about

36:07 hazard ratios for all cause mortality. That's the highest standard that we care about in medicine. Which is I'm not asking what the hazard ratio is for you getting cancer or even dying from cancer. I'm asking about the hazard ratio of you dying full stop, period, all causes cancer, heart disease, you name it. So ACM all cause mortality hazard ratio is the highest standard. The way a hazard ratio works is it's always reported as a number. with a ninety five percent.

36:32 confidence interval. All of the numbers I'm about to spew out. Have a ninety five percent confidence interval. that puts them in the statistically significant category, meaning we are at least ninety-five percent confident that these numbers are not by chance. A hazard ratio of one means That this

36:51 behavior. has no effect on all cause mortality. A hazard ratio of one point one means it is increasing risk by ten percent. one point one five would be fifteen percent Two point one.

37:07 would be one hundred and ten percent. You're subtracting one from the number and that's your percent. A hazard ratio of point eight five would be a fifteen percent reduction. Has a ratio of point seven, a thirty percent reduction in risk, et cetera. Okay. So now we go about doing the analyses and we look at enormous populations.

37:27 And we apply statistical corrections. And we say, Lo and behold, what is known. Okay, so we talked about smoking earlier. We know smoking is bad, but how do you quantify how bad it is? Well one way to do it Is to take People who have smoked a certain period of time, let's just say we say, Let's take all the people who have smoked

37:44 twenty pack years. At least. So they've smoked, say, a pack a day for twenty years or two packs a day for 10 years. And let's compare them to people who are identical as best we can make them statistically. Except. That they weren't smokers.

37:57 No. Is that perfect? Absolutely not. Here's why. Anybody who's a smoker. versus a non smoker, there have to be other differences between those people that we can't correct for.

38:08 Because a smoker by definition is not going to be as health conscious. So even though we think we're correcting for what they eat, we know we're not fully connecting for what they eat. Exercise, et cetera. So all of these numbers. You have to take it's almost amazing that we put decimal places on them. We should almost round them. Yeah, yeah, yeah. I think we're putting false precision on them. But nevertheless.

38:29 The hazard ratio for smoking and all cause mortality is about one point four one. Call it one point four. Meaning Directionally. At any point in time.

38:39 A smoker compared to a non smoker has a forty percent chance greater death rate in the coming year. Again. Not surprising. I mean it is amazing and it is amazing that people still smoke, sadly.

38:51 But yes,'cause of course smoking impacts every chronic disease, right? It's enormously increasing your risk of cardiovascular disease, cerebrovascular disease, Alzheimer's disease, and of course cancer. Okay, let's look at type two diabetes. Type two diabetes, again, depends on the study. Directionally speaking, it's about 1.3 to 1.4 is the hazard ratio. So roughly a 30 to 40 percent increase in.

39:14 in all cause mortality. If you look at hypertension, having high blood pressure, it's about one point two. So about a twenty percent increase in all cause mortality. Probably the greatest

39:28 Example of these would be, you know, something like end stage renal disease. So There's a patient whose kidneys don't work anymore, they're now on dialysis. And that comes with a lot of other medical baggage.

39:40 Of course, that bakes in a lot of other diseases. A lot of times those patients already have devastating hypertension, type two diabetes, et cetera, as the precursor to that. Not always, but often. And that comes with a hazard ratio of about two point seven five. That's a hundred and seventy five percent increase in all cause mortality. So let's think about those for a moment. That capt a lot of the nutritional stuff. Like if you put obesity in there, it's gonna be maybe one point one. about a ten percent increase. And that's lower than type two diabetes because of course obesity per se.

40:12 Actually isn't it. highly associated with mortality if you normalize for metabolic health. So Obesity is just a very crude, easy to measure proxy for bad metabolic health.

40:25 But Technically only about seventy percent of people who are obese are metabolically unhealthy. About a third are not. Similarly About twenty percent of lean people are metabolically unhealthy and their risk is much higher. So

40:40 The real issue is metabolic health, but nevertheless, just to give you a sense of it, obesity And type two diabetes, you're seeing we're talking about somewhere between one point one, one point three. So there you're basically seeing the impact of nutrition. Similar exercises with sleep. People who are

40:55 Sleeping less than sleeping more, yes, there's unquestionably a higher association with mortality, but it's really on the order of One point one, one point two, one point three, one point four. Not to diminish those things, but when you start to compare those results to the exercise results. And again.

41:12 Don't look at it through the lens of people who exercise versus people who don't. You look at it at the end stage. That's why looking at type two diabetes is the integrator. Yeah. So what's the integrator of exercise? Well, the two best ones, three best ones.

41:28 Or VO two Max. muscle mass and strength. Because you can't have a high VO two max without doing a lot of hard exercise. You can't be in the top

41:39 decile or quartile for muscle mass and strength without doing some work. It doesn't have to be necessarily exercise, by the way. You can just have a very physically demanding job. But the point is. There's no way to hide behind it. when you look at these integral functions.

41:55 And here the hazard ratios, Patrick, are staggering. When you compare top decile to bottom decile for strength, we're talking about hazard ratios of three. two hundred percent difference. The biggest gap is when you compare the bottom twenty five percent.

42:12 For VO two Max. Have you ever taken a VO two max test? I haven't taken one. I know the concept that I haven't taken a test. It's a test where you'd either be placed on a treadmill or on a bike. You'd have a mask strapped over your nose and mouth. That would be incredibly precisely measuring your oxygen consumption because we know that the air you're breathing in is twenty one percent oxygen. So it's just got an O two sensor and it's measuring how much

42:37 oxygen is coming out. So if it's coming out at seventeen percent, it knows four percent was consumed. That is converted into a flow rate. As you're doing this test. It's measuring how much oxygen you're consuming in liters per minute.

42:49 Now You and I are sitting here having a discussion right now, our oxygen consumption rate is incredibly low. It's about three hundred milliliters per minute.

42:59 That's low. when you're exercising The more demand your muscles place on the generation of ATP, the more oxygen you consume. And that number goes up and up and up and up. And by pushing you and forcing you to exercise until the point of failure, we will at some point achieve a maximum level of oxygen utilization. And that's called your VO2 max. And that number is more predictive of how long you live than any other number we have.

43:24 So if you take people who are your age, your sex, and you compare the bottom twenty five percent to the top two and a half percent. The hazard ratio is A little over five.

43:36 There's a four hundred percent difference in all cause mortality. Now, some people are gonna say, Well come on, Peter. Who could be in the top two point five percent? And the short answer is Actually anybody could. It's just a question of how much time you want to train and how long you want to be training. It's a consistency game. You don't have to train twenty hours a week. You can train a fraction of that, but you just never get out of shape. You just Constantly work towards improving that.

43:59 But if you take even Something more modest, which say, What if you just take the bottom twenty five percent? And compare them. So call that the first quartile compared to the third quartile. So people between the fiftieth and the seventy fifth percentile. Now that's not a stretch.

44:12 There's no human being that is not capable of being in the third quartile. For their VO two max. So when you compare bottom quartile, which is basically people who are never doing any exercise to third quartile. Which could be achieved.

44:26 Doing five to six hours of exercise a week. You're talking about a hazard ratio of two point seven five. A hundred and seventy five percent difference in all cause mortality.

44:40 So it's going through these types of analyses, Patrick, that makes it unequivocally clear that exercise is indeed The greatest driver, the greatest lever we have at a longer life. But it comes with a caveat, which is it has to be the right kind of exercise. These generic

44:57 recommendations of just move, just be active, just garden a little bit. No, that's not gonna cut it. I mean those things matter, but you won't get the benefits I'm talking about. Without doing much more specific training geared towards strength and cardiorespiratory fitness. I love the Nassim Talib idea of don't tell me what you think, just tell me what's in your portfolio. I'd love to understand your portfolio of exercise.

45:20 That's one of the things that really stood out to me. Reading the book was the exercise that I'm probably personally most inclined towards which would be like a six mile trail run or something. Not like all out, just probably like a zone three, zone four kind of thing.

45:34 It's fine. Like I get a lot of joy out of it, but it's maybe not the ideal thing to form a great portfolio of exercise. So what has become your portfolio of exercise? Because I think You've got all the data, so you tell me what's in your portfolio. Three comments. First of all, I wasn't aware of that statement by Nassim. That's a great statement. put your money where your mouth is. I don't really care about the pontificate and just tell me what you're doing.

45:54 Two, I would disagree with you, and I think that that's a great piece to have in your portfolio. I think that's super important for two reasons. One, it's actually great exercise. That should clearly form a basis of your aerobic training. Secondly There really is No better way to integrate physical health and emotional health than outdoor exercise.

46:15 So Michael Easter, who's a good friend of mine, and wrote an amazing book called The Comfort Crisis. I'm not sure if you've read that. Oh no, I haven't heard of it. You should read the book and you should interview Michael. Talks a lot about The benefits of being outdoors. from a standpoint of just our natural evolution.

46:32 So he argues in this book. I've gone back and looked at some of this literature. We'll never know the answer to these things'cause you can't do the experiments. But teleologically the following makes sense. Did we evolve around symmetry? No chance.

46:45 We never saw Symmetry. For a billions. Right. Meaning going back to when we were Worms and flies and things like that.

46:54 We never saw symmetry. Nature is fractal. It is completely asymmetric. It's at least plausible that our hyper symmetric, perfectly manicured indoor worlds Or at least If consumed in excess.

47:11 Not necessarily great for our psyche. There is something regenerative about being outdoors. There is something regenerative about being in nature. Even if again, we can't know that for certain. There are studies that have looked at that by doing functional MRIs, and they all seem to suggest that, but I can also poke holes in those studies. But I think

47:32 I can't deny the experience that I have when I go outside. And If I'm at the end of a long day. I open my day by exercising and I close my day before dinner by another type of exercise. So I'll answer your question in a moment, but rucking has become kind of an obsession of mine where

47:48 Basically I just put on like a sixty pound backpack and I go for a walk before dinner. And A it's physically strenuous, right? Sixty pounds walking around up and down the hills of Austin is pretty strenuous. But I don't take anything with me. This is a very important part of it. There is no phone. I'm not listening to podcasts, audio books, or music. And

48:05 It's just it. All I can hear is the breeze blowing. And the window moving the leaves and things like that. And that's a very important forty five minutes to an hour for me. And then I come home.

48:17 Have dinner and get on with the day. Okay, so to answer your question. You're getting that through trail running. You're being out there, you're getting the work out. It's a much better workout than say if you were running through the city. Okay, so my portfolio

48:29 Is Purely focused. On being the best version of myself physic in the last decade of my life. So everything is geared towards solving that problem.

48:42 Which the model I use for that is called the Centenarian decathlon. What are the most important physical events. Or things, activities of daily living. and sports and activities that I want to be able to do in the last decade of my life. So call it

48:56 Eighty to ninety. Let's assume hopefully I can live to ninety. So what am I going to be doing between eighty and ninety? And then Everything has been reverse engineered from what those activities are to what physical skills I need to have. So how strong do I need to be? How much aerobic efficiency do I need to be? How high a VO2 max do I need to have?

49:13 How much balance do I need to have? How much foot reactivity do I need to have? All of these things. And so what I'm doing is About four hours a week of Steady state zone two cardio.

49:25 About thirty Minutes a week. Up to sixty minutes a week of higensity cardio. So pushing that VO two max system. About six hours a week of strength training. That's split.

49:38 Mostly equally between Upper and lower body. And within that there's lots of details. What am I doing? And then rucking. Probably three to four hours a week of rocking.

49:48 When you say it that way, it sounds like a lot. but I want to talk about like the mental side of the physical working out. Because I think a lot of people think of this as like a nasty tasting medicine. They wish there was some spoonful of sugar that helped the medicine go down. But my experience with exercise is that in the period between when you start when you don't want to do it to when it's habitual.

50:08 There's this kind of like valley of death where it sucks. On the other side of that valley. It's actually all sugar, like it becomes the best part of your day, not an obligation. And I'd love to understand why that is. I'm not sure if you experience it the same way, but

50:21 For me. When I'm in shape. There is nothing that I am more excited for than like a long hard Trail run. Whereas right now I'm not in particular good shape and

50:32 the thought of getting going again. It's like ah damn it, you know, it's gonna burn and hurt. My lungs are gonna hurt. Everything's gonna hurt. But it seems like that's like a misunderstanding that it's like a medicine when in fact It might actually be like the greatest experience once you get into the habit of it. Are there underlying biology reasons? For that experience of almost euphoria associated with exercise? Certainly much has been said and and written about endorphins, which are

50:55 literally chemicals that are produced by muscles There are many chemicals, by the way, that are produced by muscles. They're called myocines. So yes, there are absolutely neurochemical signals that do make us feel better when we exercise. I try to understand this through the lens of other people. So for whatever reason Exercise has always been something I've loved. So it's harder for me to relate to the people

51:19 I know these people, right? I have patients who say, Peter I hear what you're saying and I know this is important. But I just don't like it. And I'll do it because the data are so compelling. There's no joy in doing this, or I need to find other ways to make this enjoyable, which means I have to do it with somebody else. I can't do it without a trainer being there. Or I can't. do this without having, you know, a movie on while I sit on that bike and suffer.

51:42 And I guess I would say that's okay. It's better than the alternative. And certainly if you can find ways to bring other things into it, such as being social while you do it. I think that's great. I also think that you're right in that

51:55 Once you get over a certain threshold The consistency is there. I think there's no feeling like it. And there are many days even now when I don't really want to exercise. Usually for me it has to it's more of a temporal issue. So If I don't get my work out done first thing in the morning when I normally do

52:13 I just develop apprehension about the day and my desire to go in even an hour later is lower. Now I'll always make myself do it. But it might take half an hour before I Relaxed. And enjoying the work out.

52:25 So I can at least relate to that component of it, which is Uh, I just have this apprehension I should be doing something else. The emails are piling up and Whatever else is sort of getting in the way.

52:36 But yes. Maybe there's an analogy here to investing. If you're talking to kind of a thirty year old Who's finally starting to pull in a big enough paycheck that they don't have to live paycheck to paycheck. There is a discipline that comes from saving.

52:50 And it's not easy. But if you get into the habit of doing it automatically And it's no longer a decision. I'm signing up for a four oh one K plan and that money is coming out of my paycheck before I see it. It hurts a bit less.

53:04 than if you have to make a decision about it every single time. you get a paycheck or you get your full paycheck and then you have to go in and make some decision to go and invest it or something like that. And I think with exercise If we just automatically decide we're gonna do this thing, it's gonna be done early in the day. I am an advocate of doing it early. I do find that compliance is much easier if it's done before you start work than after work.

53:29 And I also think it sets your brain up better for the day. So part of that is just developing a habit around doing something. And then before you know it, it Actually becomes pretty automatic. It's hard to go there, especially when you frame things in terms of hazard ratios.

53:45 And I just know we're about to collapse those a lot. But I asked the question because of our first conversation where we talked a lot about caloric restriction, dietary restriction, time restricted feeding. And just this kind of general concept of nutrition where Intuitively it seems like

54:00 If I eat nuts and salads And good lean protein. I'm gonna feel better than if I eat chicken fingers for every meal. Not much more to be said about it than that. But it seems like your personal views and the data have evolved quite a bit from say six years ago when you and I first met and talked about this.

54:17 Can you say how they've evolved? And the degree of importance that you place on nutrition, let's say with your patients or for yourself. Relative to six years ago? I think nutrition is obviously important and when it's really out of balance it's You wreak havoc.

54:32 Yeah, absolutely. Just as the same is true with sleep. So If a person is sleeping four or five hours a night Either through choice or through pathology. That has got to be fixed.

54:44 you're not going to make tremendous inroads on anything else. If they're Sleep. Is that bad? But once you get to the point where you're sleeping seven to nine hours per night, which is

54:58 Basically the Oh, I don't know. That's probably the two point five to ninety seven point five arc of the distribution. Once you're in that zone. And your staging is reasonable and you're feeling well rested when you wake up.

55:14 That's it. You don't really need to worry about this problem anymore. One of the things I get a little bit concerned about with the proliferation of sleep trackers is is we get a lot of people who are sleeping just fine. They're getting seven and a half hours of sleep a night. They feel fine, but their sleep tracker is telling them there's a problem. And it's creating so much angst. That doesn't need to be there.

55:34 I had to stop them for this reason. Yes, exactly. And I do. I force patients to take tracker holidays. And I sometimes do myself, if I just get a little annoyed. So The point is that Sleep.

55:46 is an area where you can really get punished if you're outside of Optimal, but once you're optimal, there's no super optimal. I think The data would really suggest the same is true for nutrition. If you're really

56:02 Undernourish or overnourished? Those things should be corrected. probably the overnourished is a bigger problem. I mean it clearly is from a numbers perspective. It might also be health wise a bigger problem, at least In the developed world. Once you're in that zone of being

56:17 Adequately nourished. It's far more important to be focusing on metabolic health. And lean mass. than to be thinking about The subtle nuances of

56:30 Well, how much fruit should you eat? Right, right. The reality of it is I don't think that those things aren't important. I wanna be clear. There's many topics I did not write about in this book for the sake of space and time. And certainly one of the things I'm very interested in is the relationship that Soil has on food. This is a rabbit hole I've gone pretty deep down.

56:49 And I think there's very little doubt that food grown today doesn't have nearly, maybe even half the nutritional value. that it could have or should have if the soil it grew in were healthier. So

57:03 There's no doubt that we could be eating better food. But I also think most people tend to over index that at the expense of Exercise. You know, if you look at

57:16 the absolute battles that people have over social media. With respect to this diet versus that diet and What about being vegan? What about being paleo? And it's like it might not actually matter as much as you guys think. Are you in Energy balance.

57:30 Are you metabolically healthy? Are you getting enough protein? After that. I almost joke that I didn't want to write the two chapters on nutrition. Because it creates so much substrate for people to argue about things. And what I really want to say is like

57:43 Those are the three questions that matter most. And the rest is just tactics or and strategy around what to do. And if Course I go into all those things. How do you use dietary restriction, time restriction, caloric restriction? Two

57:55 address the crisis of overabundance. Which we have. So most people are overnourished. And I don't think there's some magic around how you fix that. The operationalizing of it is hard.

58:05 But the strategy is really simple. You can calorie restrict, dietary restrict, or time restrict. Each one has advantages. Each one has disadvantages. They're not mutually exclusive. But they are collectively exhaustive. Try the one that works for you. If you fail, go try another one.

58:21 What I'm trying to get away from is kind of the dogmatic view that there is a right way. Is there a VO2 max equivalent benchmark for metabolic health? I'm just trying to understand like what metabolic health actually means. There isn't a single number the way there is for peak aerobic performance, but there are several things that do matter. So one of them is actually also a functional test. So If you look at a person's zone two capacity, so zone two

58:48 is this is a very technical definition, but basically the highest amount of work you can do. So wattage on a bike, for example. While keeping lactate below two millimole. And lactate below two millimole seems to be empirically the place at which you can maintain a steady state where lactate doesn't net begin to accumulate. So at a lactate of two, it seems that you are able to maximally produce

59:12 And clear simultaneously, so that the level doesn't get above two. A more practical way to assess that. Is About the highest level of work you can do. While still carrying out a conversation

59:26 Albeit. Difficult. So If you can't carry out a conversation. You're out of zone two. You're into zone three.

59:34 If you can speak. But it's easy. You're in zone one. So zone two, especially the upper end of zone two is I did a zone two workout today.

59:45 My wife and I'm doing it on a stationary bike. If my wife comes in and starts talking to me, I can talk to her. I just don't really want to. If my brother calls me, I'll pick up the phone and We'll talk.

59:55 But I'll also say, Hey, can I call you later? But I can certainly carry on a conversation. So that's what we call the R P E way about determining it, the rate of perceived exertion. But the more technical ways to do it would be doing it based off lactate levels. You can estimate it based on your heart rate, but truthfully, I think that perceived exertion is the best way to do it for the average person who doesn't want to be checking lactate levels. Well,

1:00:17 The more work, the more wattage you can generate. at that level, the more metabolically healthy you are. If you look at someone with type two diabetes They can barely put out one watt per kilogram of body weight. Before they exceed that threshold.

1:00:32 If you look at the best cyclists or runners in the world. They could put out four watts per kilo. Before they exceed that threshold. A master's athlete might be two and a half to three watts per kilo. So where you are on there is huge.

1:00:49 Then we look at other things like glucose disposal. So using something like an oral glucose tolerance test. what happens when you're challenged with seventy five grams of glucose. How much insulin do you require to put it into your muscle and how high does your glucose get? Before you put it away. Looking at

1:01:05 Other markers like triglycerides, which are Another marker of fat storage in the liver. Looking at Transaminases. Inflammatory markers. All of these things kind of factor into it, but no, there is not one single number that is the integral of it, the way that we have for peak aerobic performance.

1:01:21 What do you hope? happens to the industry of health and health care. In the coming decade or two. given everything we've talked about today and This hopeful transition to medicine three point oh to address slow death.

1:01:35 you mentioned earlier being more patient led and dragging the healthcare system along. Could be a feature. Not a bug. But holistically. What do you think the healthiest thing that could happen to the industry itself is?

1:01:48 The challenge with the healthcare industry is that it has Three Issu that are equally important and intimately linked. And every time you try to

1:02:01 Solve one. Even if you make improvements in it, you tend to make the others worse. So Those three issues are quality of care. access of care and cost of care.

1:02:13 And If you take stock of where the United States is We're pretty good on quality of care. In fact. Despite all of the things we'll say negatively about the US healthcare system.

1:02:26 If you can afford and gain access to the best care For medicine two point oh problems The US system is very good. No, it doesn't have

1:02:36 great care on the medicine three point oh side as we've discussed. But it's pretty good on the medicine two point oh side. But Access is pretty bad. Medical

1:02:45 Costs are the leading cause of personal bankruptcy. And our per capita spend on Healthcare is Unbelievable. I

1:02:55 God, it it's gotta be like fourteen or fifteen thousand dollars per capita at this point. I mean, it's absurd. Crazy percent of GDP. Yeah, yeah, yeah. It's about eighteen percent of GDP. It's out of control. It'll bankrupt us before anything else does. I'm convinced We will have to address this problem before any other problem. For solvency. And then the third one. Is

1:03:15 access to care. So you have both the cost issue, which we just addressed, and then you have how many what fraction of people are uninsured or underinsured and suffering these problems. So I don't have a solution for that problem. I mean, I wish I could sit here and say, Oh, and the solution is we just have to do this, because you don't. There are like ten things that have to be done. To address that.

1:03:34 Then I think a lot about that problem. That's not what I'm really writing about. I think what I'm really writing about is at the individual level independent of those problems being fixed, what can you do? 'Cause I certainly for my health and the health of my patients, don't want to wait for the system to get better.

1:03:49 I don't wanna have to wait for medicine. as a system to switch to three point oh or wait for costs to come down or wait for access to be expanded to everybody because I do believe that healthcare should be accessible to everyone. I do believe healthcare is a right and not a privilege. And I think that We do require

1:04:09 Some single payer. involvement. I don't think a sole single payer system will not solve our problems. It will solve one problem. It will solve access. Might even solve cost. Then it will erode quality. Just look at what's happening in Canada and the UK. It's gonna have to be a super complicated

1:04:25 solution. Of which I have lots of thoughts, but again, not thoughts I wrote about Because I just felt it was more impactful to write about it at the level of the individual and what they need to do for themselves. Thinking back to my little mantra, incredible amount of insight around this notion of strong body, both through exercise and nutrition and sleep and

1:04:45 Some of those numbers are just staggering. And I think even just for me, I consider myself a very active, healthy person, like it's so much motivation to really emphasize Exercise and a strong body. What about Calm mind.

1:04:58 Have you learned through your own experience through Research in the data through working with patients. When I say call mind What does that bring to mind in terms of both importance as an end?

1:05:10 And also the means to achieve that end. Well, I mean I think there's a definitely a couple of ways to think about that. So Anybody who's ever played around with Mindfulness based meditation.

1:05:21 Which I have. Quite a bit. is sobered. To realise. How noisy the mind is.

1:05:28 That type of meditation for folks who haven't done it is a meditation where You focus on An object, usually the breath. It's an easy one to focus on. And the whole goal of the meditation is just to be as aware of the breath as possible and to notice

1:05:43 Every time your mind wanders off the breath onto a thought. And the exercise Is Making that realization.

1:05:53 And bringing The mind back to the breath. So Contrary to maybe what people might think who haven't done this meditation, the goal is not to stop thought.

1:06:01 Because that's not actually possible. It's not possible for more than In my case, a few seconds. The goal of that exercise. Dan Harris, I think, says this so well. He's like

1:06:11 the muscle, the bicep curl of meditation. is the exercise. of noticing that the mind wanders and bringing it back. Two the breath or the object of meditation. And if that happens

1:06:25 A hundred times in a ten minute. meditation session, that's not a failure. It's not that you failed a hundred times. It's that you got a hundred reps in. Nice way of thinking about it. Yeah, I think that's one of the most compelling arguments I ever heard for meditation, you know, the very first time I heard Dan say that. So what does a calm mind mean? Well I it doesn't mean a mind of no thoughts.

1:06:45 Maybe there's some Buddhist monk. For me it means And awareness. Of

1:06:53 when my mind is hijacking my behaviors. That happens a lot. For me that's been learning to develop An emotional awareness. So that means

1:07:04 recognizing visceral sensations. So for example yesterday My wife got upset at me for something and It was actually being able to stop and notice the the physical feeling in my stomach. As I was getting angry.

1:07:20 So she was getting upset at me. And I felt like she was kind of harping on a point that she'd made ten times and I sort of felt like Okay, you're right, but you don't need to harp on me for the tenth time. And so

1:07:34 The difference is Five years ago, I would have barked right back. And I would have escalated. And Yesterday instead I was able to

1:07:43 Pause. Notice the sensation. Understand that I was getting irritated. And Simply not react. And

1:07:53 Just say, you know what, how about I apologize again? Yes, I've apologized nine times. And I probably don't need to apologize a tenth time. Like in other words, it's not my obligation to do so. But harmony matters more to me than being right. And in the end, she is right. Everything she's saying is right. I'm just annoyed by the fact that she's

1:08:10 needing to tell me for the tenth time that she's right. So I just said, Okay, yeah, you know what, honey, you're right. I'm really sorry. That was dumb of me to do and I should have been more clear about X, Y, and Z. To me that's calm mind.

1:08:24 It's almost slow mind, maybe for me, is how I think about it. When I think about calm Mind. It very closely relates to the last one, which is Houseful of Love. Another way of saying that is The value of relationship.

1:08:36 maybe the house with your wife and kids being the most important, but not ending there. And that in my experience as someone that really does Is not imbued with a calm mind, but rather with a fairly like Hyper sensitive hyper vigilant.

1:08:50 Mind. Yeah, Calming it. In some weird way it makes room for More love in the house.

1:08:57 In an interesting way. And I'd love to hear what you've learned about. The importance of household of love. relationship. Where that

1:09:05 slots into this big discussion about what it means to live Not just a healthy and a long life. But a good life. And it seems like this final category is the arbiter of that. We don't have a VO two max for that. Or maybe we do.

1:09:20 But I've seen you talk about eulogy versus resume virtues before. What an incredible powerful little term. And I'd love to hear your thoughts on the house full of love and its importance. Yeah. And of course I'm Taking that from David Brooks, who wrote a great book called The Road to Character, which is one of the books that I

1:09:40 stumbled across in the airport. During the in the depths of my despair. And I got very lucky.

1:09:48 This was March of two thousand eighteen. I was really at Kind of a rock bottom. I got invited to give a talk. Overseas.

1:09:56 And The talk happened to be on my birthday. And normally it would be like well I can't go'cause it's my birthday. Like I'm not gonna go and miss my birthday with my family. But at the time things were so bad at home that it was like a no brainer. It's like uh of course I'm gonna go because

1:10:12 It's better than the alternative, which is sitting here alone and not being able to celebrate my birthday with anybody. So I went and in the airport I happen to pick up David Brooks's book. I don't know why. I don't know what drew me to it, but sure enough I just grab this book, The Road to Character. And the book talks about the differences between eulogy virtues and resume virtues.

1:10:30 And It was just the right thing for me to read at that moment in time and I realized Boy. And it's an obvious realization, but I don't think I thought about it through this way was Everything I've done to date.

1:10:42 And at the time, how old was I? Forty five, I guess. Every single thing I've done to date has been resume boosting. Nothing has been eulogy boosting. My eulogy is going to be very

1:10:55 Hollow. It'll just be the usual platitudes that people say. my kids, if they were old enough or my wife would really have much to say about me. That is exceptional. They could talk about how smart I was and how hard I worked and

1:11:08 All of these things, but I know deep down that that's Irrelevant. That was a real turning point. Now, like most turning points. at least turning points of substance, that doesn't immediately result in a change.

1:11:21 It's a Very Slow Process. But that's part of the stone.

1:11:28 Mason hitting the stone. And yes, eventually that stone is going to break and it will break, of course, as the Jacob Reese quote. Is not from that. hit, but all the ones that came before it. And that was a very big hit that didn't result in the stone breaking But was clearly a part of the stone finally breaking

1:11:46 Couple years later. If you think about The Evolution of Purpose.

1:11:52 in your life. And that's something I'm just always thinking about and curious about for other people. Can you describe the role of purpose in life and The degree to which you feel like you are operating from a virtuous purpose or clearly defined one. We think about this with companies all the time, like

1:12:10 Most people just don't know what they're doing or why they're doing it. They're just doing stuff. And very often purpose is borrowed. This is like the mimetic idea. Like everyone else seems to want this, so I guess I should. So I'll do the stuff to get that thing. How is your own feeling of purpose or definition of purpose.

1:12:26 evolved over time and anything you would share with others that might be considering that same question. Yeah, and it's an area where I just I feel like I have such little knowledge beyond

1:12:39 Myself. I hesitate to extrapolate. So I can only say that for myself. Sense of purpose. is something that is becoming narrower and narrower.

1:12:49 And for me that's a good thing. So for some people they need a bigger and bigger sense of purpose. I think for me I have always From the youngest age

1:13:00 due, I think, to so much of the insecurity and inferiority that I felt. believed I needed to have the greatest sense of purpose. And I needed to have the greatest impact. And I needed to be doing something spectacular. With each passing

1:13:18 Day. I will tell you that my sense of purpose and my focus is becoming narrower and narrower. And I don't care about much outside of my family and my friends in terms of my sense of purpose. My sense of purpose as a father is far greater

1:13:34 than any sense of purpose that I have as a doctor, as an author, as a podcaster as a you know an investor All of the other hats that I wear that do give me purpose and do give me joy and do challenge me and all those things.

1:13:48 They don't compare to the thing that matters to me most, which is Are my kids. going to be well adjusted humans. Are my kids going to

1:13:59 have the skills to avoid the pitfalls that I fell into. And what am I doing about that? And also There's an urgency about this that I don't feel with anything else, which is We have such a small window of time.

1:14:14 To be with our kids. You know, I heard on a podcast the other day and I've seen these data elsewhere. So I I think this is This is the Tim Urban thing, how you spend like all your time with your kids by the time they're eighteen. That's right. By the time they're eighteen, you're pretty much done. And in my case it was even less. Once I went to college I never lived under my parents' roof for another day because even in college I stayed in the town and got jobs in the math department or things like that.

1:14:37 And then boom went off to medical school in another country and then I was never back. been back to Canada a handful of times. So When I think about it through that lens, I'm like, God, nothing else matters. This is the only thing that matters. I'm sure there are some people who could use a little bit more

1:14:53 sense of purpose and Also need more purpose and fulfillment from their work outside of their family. But for me I think it's been more about shifting it back to what I truly think matters more.

1:15:05 It's amazing to me. hearing you talk at the beginning and now at the end of our conversation about The motivation for large effort and purpose. Being Building evidence.

1:15:15 to disprove an insecurity. Like like it's such an unhealthy Think so many successful people My friend Graham Duncan has this idea of the insecure overachiever. And the incredible things that they tend to do. They tend to be able to move mountains and the effort and the accomplishment look so impressive from the outside.

1:15:33 But the intrinsic motivation maybe is unhealthy and then You saying having a narrower and narrower purpose. It feels like permission almost. to Embrace a healthier form.

1:15:45 Of motivation. I find that to be a very lovely idea. If we think about Closing down our conversation. And everything you've learned in the book.

1:15:55 And I forced you to condense it down to an index card that Maybe I'll do this. I'll pay to have it sent. Everywhere or Plain fly overhead and Drop them over New York City or something.

1:16:05 What would you put on the index card? What's the font size? Up to you. Legible. No, it's funny. I was interviewed the other day I forget it was an outlet. Like it was kind of a media outlet and they They asked me a question that I've been asked so many times and it's typically you're asked on these morning shows and stuff.

1:16:23 The question was like What is the secret to longevity? Like what's the one thing? The first ten times I was asked that question, I came up with some sort of nuanced answer. And then the final time I was asked yesterday, I just said you know what? Honestly, if it could be distilled into one thing, I wouldn't have written a four hundred and eighty nine page book. It's not amenable to that.

1:16:43 So I won't attempt to do that, right? I won't attempt to synthesize the book into a three by five index card. I don't know the answer, Patrick. That's a very hard question because It's going to really depend on who's reading it. My mom used to wear this shirt that said Eat right.

1:17:00 Exercise die anyway. Shitty question. Well, I think it's like look, maybe you have several versions of those cards and Given that this is just a magical thought experiment. When you sprinkle them out of the airplane over New York City. We imagine that each card lands in the hand of the right person.

1:17:23 If there's a person who's just not exercising much That card is just gonna talk about You can literally add ten years to your life if you adopt this. And oh, by the way. you're gonna feel and perform and function so much better, especially at the end of your life. When most people are in so much pain.

1:17:41 If it's the person who We didn't talk about this kind of stuff, but if this is the person who has an elevated LP little A and doesn't know about it, maybe the card simply says, Go and get your LP little A checked. And getting this addressed is gonna Save.

1:17:55 fifteen years off your life when you don't have that premature heart attack that you don't know is coming because you don't know what L P little A is. And by the way, if it's the Person who's outwardly successful or not outwardly successful, but who's in entirely miserable in their relationships are all in hell, sort of the person I was, then the card is gonna say something about

1:18:14 You gotta stop everything you're doing and get help here. And you have to to be willing to address the demons that got you in this position and nothing else is going to matter until you fix this and it's all It's all a shell game. You're just numbing your pain. with achievement or wealth or whatever else you're pursuing until you get this addressed. So

1:18:32 We could probably come up with a dozen of those. Index cards and just I don't know. Math gets them in the right place. On the back of my shitty morning show question.

1:18:42 You've done a ton of interviewing of your own now. What have you learned about doing that well? As with many things I've seen you do, like It seems as though the rate of improvement has been We were good to start, but it recently

1:18:55 I think they're just incredibly dense and interesting and Clearly like on the thread of your own curiosity. Like you're not filling in a chart of topics. You're pulling a thread of your own curiosity with the world's best people. on those topics and the topics obviously they center around health, but they range widely from there too. What have you learned about the experience of interviewing

1:19:16 So many talented people and doing that well. Something I'm always trying to get better at. Yeah, so am I, Patrick. It's hard. It's really hard and There's a part of me that wishes it was all I did.

1:19:28 So when I meet people who for whom podcasting is their job. I'm quite envious because I think God, if I had 20 more hours in my week or 30 more hours in my week to put into this, how much better could I get? For example, one thing I don't do, I never go back and listen to my podcasts. So

1:19:45 A lot of times in an interview, I'll screw something up. say something and I'll realize that wasn't the right question. But that's nothing compared to what I know I would get if I went back and listened to it as an observer on the outside. So that's an enormous shortcoming There aren't enough hours in the day because I've opted for something that I think is even more valuable, which is I listen to other podcasts.

1:20:07 And I'm listening. for podcasts where there's a confluence of two things. My interest in the topic. And The

1:20:16 quality of the interviewer. There's six or seven podcasters, you being one of them, Patrick, who I really love listening. to both the content. The content is interesting to me. But also they're very good interviewers and I learn. Barry Weiss is one of them. Sam Harris is one of them. I could rattle off who all these people are.

1:20:35 And I'm a student of this stuff and I just want to get better and I think I started out at a a one out of ten. I would hate to go back and listen to my first years of podcasts. I'm probably a six out of ten today and We'll never get to be ten, but if we can asymptote at nine, that would be awesome in a couple of years. One of the coolest things about you is

1:20:53 You change your mind with the data, you change your mind with experience and through investigation. What is the frontier of your curiosity today? I think clinically. A lot of it has to do with how Can we organize all of the information we have on patients?

1:21:11 And uh Risk. Based on Dashboard. That

1:21:17 Allows them to see What we see. So behind The matrix. We internally

1:21:26 Have such a convoluted, complicated way of organizing Risk factors. We see about forty or fifty inputs into our risk matrix. Around these seven variables of cardiovascular disease, cancer, neurodegenerative disease.

1:21:41 cognitive decline, physical decline, emotional decline, et cetera, orthopedic injury. But we're still struggling with a really good way. to communicate that to patients so that they can see This input. Tweaks this.

1:21:56 Metric. Which then causes us to make this output adjustment. So We can do that in a very Crude way.

1:22:05 I think it produces good results. It would produce far better results. If the patient could see it. Just the way they could see a dashboard of their car. That's not a very sexy or interesting thing, but at the level of our practice, that's very interesting to me. Another thing that's

1:22:20 really on the forefront of what I think about is how to create the definitive training program for this idea of the centenarian decathon. This mental model Which I maintain

1:22:35 for most people who are no longer specializing in a sport or training for something in particular If you're really thinking What does it mean to be An absolute animal of an eighty year old. who can function like a sixty year old, like a fit sixty year old. Think about what that means.

1:22:52 How do you train for that? And We're doing so much work on that. That just completely obsesses me. So that's the science of movement. That's the science of strength. That's the science of training and fitness and injury prevention and injury treatment and all of those things.

1:23:06 Well, Peter, I think it's interesting that as you've described your purpose. narrowing. Subjectively. that with the book and podcast and other stuff, your impact is probably growing, which is probably a good lesson there. I have learned so much from you over the years, but I do think that

1:23:22 outlive the book really Distill so much of the incredible amount of hard work and thinking that you and your very talented team Have done together. So I'm so thankful for the book. So nice to reconnect in this format. Just a total pleasure. I've learned a lot, like always. Thank you so much for your time. Patrick, thank you so much for sitting down with me and putting so much thought into this.

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