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ketogenics was something it really was
transformational and as I discovered
ketogenics through you I'm very curious
to hear um you no longer feel the same
that you did what
changed well it's a broad topic I think
around that of dietary restriction so I
think my aperture has just widened
significantly so you have to take a step
way back and ask the question how does
one what are the ways in which one can
change their diet so let's come back to
your example in a moment
because I think if I recall when you
went on a ketogenic diet it wasn't in an
effort to lose weight no yeah so let's
put your case aside for a moment and
instead discuss it through the lens of
how most people think about ketogenic
diets vegan diets pick your diets it's
it's usually some form of energy
restriction so I think initially I was
like most people are pretty myopic about
my views of energy
restriction and over time that thinking
evolved into saying look there are
really broadly speaking three strategies
to reduce intake one strategy is to just
directly fixate on the reduction of
energy intake that's called caloric
restriction so bodybuilders are a great
example of this right like they really
really know how to weigh and measure
every single thing they're eating and
they certainly understand during an
anabolic phase this is how much energy I
need during a catabolic phase or cutting
phase I need this much and they've got
this down to a science and it's really
remarkable I mean it but it's a science
optimized for the reduction of fat
that's right that's right and
maintenance of muscle that's exactly
right longevity right for anybody so so
but but let's be clear like I don't
think there's a better example of any
type of person on the planet that's
figured out how to control intake up and
down and to produce a perfect result
with respect to that aesthetic MH well
said and for most people that's really
hard to do um it's hard to do because
you can't really ignore it like you
can't just eat without thinking you
always have to be paying attention to
what you're doing but it is the most
direct way to go about getting the
result you want so that's method one
method two
says how about I don't pay attention to
what I'm eating or when I'm eating um
but I pay attention pardon me how about
I don't pay attention to what I'm eating
or uh how much I'm eating but I just pay
attention to when I eat so that's called
time restriction people call that
intermittent fasting and if I make the
window in which I eat small
enough um I will reduce energy intake in
total so if I said to you you know you
can only have one meal a day chances are
you are going to lose weight um now
people thought that well there must be
something magical about intermittent
fasting beyond the caloric reduction but
that turns out to not be the case it's
been tested in several uh studies now
and it's clear that if you eat 2,000
calories in one sitting it's no better
or worse for you uh at least from a
weight perspective than if you eat 2,000
calories spread out of the course of a
day it's probably worse for you in
another way though which is you're a
little more likely to lose muscle mass
because you won't be able to get the
right amount of amino acids into your
muscles I I don't want to derail your
point but we are going to have to talk
about autophagy cuz I intermittent fast
like a fiend great we'll 35 y okay so
then we get to the third method of
caloric reduction which is the use of
what's called dietary restriction so
here we pick things within the diet and
we cut them out and the more restrictive
that is the more likely it is to produce
an energy reduction and therefore the
more likely you are to achieve the goal
of weight loss so the glib example I
always give is if you went on the no
lettuce diet you would not lose an ounce
right right it's simply not restrictive
enough if you went on the only potato
diet you would lose an insane amount of
weight you simply couldn't eat enough
potatoes to maintain now the that's not
a healthy diet right no one would think
that the all potato diet is going to
produce an ideal Health outcome but you
will lose a lot of weight right so keto
is simply a very for a restrictive form
of that diet and many people lose a lot
of weight on a ketogenic diet because
they are limiting so many things right
they're limiting so many carbs it's also
for many people much more satiating so
it actually readily reduces their hunger
and so they simply don't want to eat
more so they have fewer food choices and
they don't want to eat as much but you
can gain weight on a ketogenic diet if
you eat a lot you have to be careful
because you're generally eating more
energy-dense Foods on a ketogenic diet
and I've seen lots of people blow up on
ketogenic diets because they somehow
think it's a license to eat as much fat
as they want not the case so now let's
talk about so so that's that sort of
coming to that conclusion made me
realize oh well there's nothing really
magical about any particular diet when
it comes to energy
balance but now each of these diets has
their own tradeoffs around other metrics
of health so for example we talked about
the importance of protein protein is I
think the most important of the
macronutrients I know everybody wants to
argue about fat and carbs but I think
the the game is one and lost with
protein and you know the recommended
dietary allowance of protein is
unfortunately very low so there's most
people are being told to eat 8 grams per
kilogram of body weight and that's
literally half what you need to be
eating whoa yeah that's the amount of
protein for body mass that I carry or
ideal body mass total body weight hm
yeah so if I at 6 foot weighed 250 lb
I'm going to be wanting to eat something
like 1.6x that in protein in kilograms
so yeah so if you were if you weighed if
you were whatever 200 lb I would want
you
consuming at least 16 g of protein and
maybe closer to 200 depending on your
demand and depending on your age and
depending on the type of protein you're
getting so a lot of different diets
let's pick two that I think one has to
be they're doable but you have to be
careful about getting enough protein so
let's start with a plant-based diet so a
plant-based diet by definition you can't
have any animal protein so all of a
sudden you're doing away with the best
form of amino
acids you know one could argue that when
we eat animals or animal protein it is a
more pure synthesis of the amino acids
that are coming from Plants right so
like a cow all it's eating is plant but
you eat a cow or like venison is one of
my favorite things right so I'm eating
wild venison from Hawaii that only eats
grass and yet it's the richest source of
amino acids I can sink my teeth into in
other words its digestive system its
metabolism is doing this remarkable
thing I can't do which is turning grass
into the richest densest source of
protein if I want to go back and eat the
grass it's fine but I just have to
acknowledge I'm going to have to eat a
lot more of it because it's not a great
source of protein so the
bioavailability of plant protein is
about 70% that of animal protein and
it's not as rich in the most important
amino acids so when we have patients who
are plant-based and they say oh do I
have to give up my plant-based diet I
say not necessarily um and if it's
working for you in all other ways other
than this then there's a workaround here
but the workaround requires you being
very deliberate about your protein
quantity another example is you so we're
going to come back to the case that you
just said which is what about people who
are imminently fasting do they have to
you know is that a bad thing is that a
good thing well it depends but if a
person is intermittently fasting you're
going to see a lot of muscle loss unless
they're very thoughtful about their
protein intake so you know if a person's
intermittently fast lasting
168 you can generally get away with it
cuz in 8 hours you can get usually at
least three good servings of protein but
we have a lot of people who are
intermittently fasting and they're only
eating two meals no snacks they can't
come close to getting the right amount
of protein in because you can't have
let's just say you're on the 160 gram a
day program 80 grams twice in your day
is not going to cut it because you can't
put 80 gram to work it's too much
protein for the body to
Peter man this is so different than how
I live well no but think about it like
bodybuilders are very thoughtful of this
right if you look at bodybuilders I
thought we debunked all the like six
meals a day and you're saying no like I
actually do need to break it back up in
smaller pie if you're optimizing for
muscle mass yes and it can't be too
small so this is where it gets really
crazy if you're eating really small
amounts of protein like 20 grams at a
time you're not going to get muscle
protein synthesis because the liver is
going to the liver basically takes first
dibs on the protein and under
glucogenesis it's just going to make
glucose out of protein so if you just
trickle tiny amounts of protein in
you're not getting muscle protein
synthesis I'm turning it into glucose
really inefficient process yeah you're
just the liver is turning it into
glucose if you eat tons of protein and
the limit based on the literature seems
to be somewhere between 40 and 50 gram
in one sitting okay once you exceed 40
to 50 grams in one sitting the excess
just goes into glucogenesis
huh wow okay this is very so if you're
trying to get 140 g a day you really
need to optimize it by 4 * 40 and uh wow
okay so amazing this is amazing I'm
always game to change uh okay so I'm
breaking my protein up 4X 40 if 160 is
my goal what period of time do I need to
put between them because I would be
happy to do that like it I'm I what's
your feeding window what do you like to
eat when to when man I I usually keep it
tight like four 5 hours max okay so if
you really want to do it that way then
you're going to have to
have if I need to well but but but I'm
saying like if that's working for you
from a weight management standpoint and
a total caloric I'm a freak of
discipline I will never accidentally
gain weight you don't have to worry
about that with me what you have to
worry about with me is right now I
believe that autophagy is necessary to
avoid cancer I don't want to die of
cancer so I intermittent fast to make
sure that I'm in autophagy but there's
no evidence that 20 hours of fasting is
sufficient to induce autophagy yeah see
I thought there was man I thought
autophagy kicked in at like 15 16 hours
like uhuh but mice will die in three
days of not eating well that's bad yeah
so in other words like we're just it's
apples to oranges we have no I mean do
we know where it kicks in for humans no
because we don't have biomarkers for
autophagy uhuh my intuition which might
be as useful as a warm bucket of hamster
vomit is that it's probably three to
five days three to four days maybe do
you do any prolong fasting I don't
anymore wow um and I'm not opposed to it
like I would probably still do you know
if you were diagnosed with cancer what
would you
do yeah I would
probably get back to fasting more
evidence-based or just throwing
everything at it mechanistic yeah give
me the mechanism uh meaning deprivation
of growth factors yeah very interesting
also selective sensitization of cancer
versus non-cancer cells during chemo
right so there is some evidence from
wter Longo's work that when you're
undergoing chemotherapy doing so in a
caloric deficit can be beneficial
because the cancer cell is
differentially and disproportionately
stressed by restriction and than the
normal cell and therefore you're CU
remember chemo like the magic of chemo
is not that it kills cells or kills
cancer cells it's that it selectively
kills cancer cells anything can kill a
cancer cell it's how do you kill a
cancer cell and not a regular cell so
how do you how do you enhance the spread
between those two and it might be that
caloric restriction is a way to do it
and it renders the cancer cell even more
susceptible and at the same time that
you're hitting with chemo it becomes uh
more likely to die at the expense of the
healthy cell that's that's the mechanism
and there is some data to suggest that
that's the
case Okay so uh autophagy we know is
going to kick in at much long we hope is
kicking in at much longer periods uh
deprivation can still help with cancer
from a growth factor remember you also
kick in autophagy with exercise so if
you're looking for another absolutely
what what is autophagy right autophagy
selfing well yes yes yes but what it's
occurring in nutrient absence M and
there's a great way to induce cellular
energy reduction which is exercise when
you exercise cellular energy goes down
that's why exercise increases kinas
activity just as fasting does H so we
you you don't want to underestimate the
benefit of exercise in tricking the cell
into thinking its nutrients are scarce
okay then what kind of exercise I'm
going to guess it has to be the kind
that I hate the most most and if V2 Max
is the under the curve revealer uh it's
what we were talking about very high
intensity period of rest very high
intensity well that's how you train V2
Max but that is that what I have to do
no because that's only that's that
should only be 20% of your cardio volume
80% of your cardio volume Should Be
steady state uhhuh and moderate
intensity okay the 80% I like that a lot
better interesting that's zone two as we
call it and that's done at a level where
you could carry out a conversation if
you had to but you don't want to right
that's the that's the litmus test that
is a perfect description okay so uh
going back to protein so maybe in fact
no you're you're saying just flat out
the intermittent fasting is probably not
helping you at all and if anything it's
probably making it hard for you to get
protein and spare your muscle uh you
need to spread this out you spoke in
kilograms which really threw me off
that's okay how much do you weigh in
pounds uh 185 Okay so
160 to 180 grams per day so four meals
at 40 to 45 grams is perfect for you
okay spread out over ideally as long as
possible and to be clear these don't
have to be meals like two of my four 45
gram of protein that's a [ __ ] meal
it's not though think about it like what
is that 200 calories it's like a chicken
breast it's yeah that I mean you don't
consider that a meal that's a rounding
error um no for me like I'm doing I'll
do like I have these venison sticks that
are 10 like a little jerky venison
bought or made uh they're actually now
bought you can now buy them I like that
y okay um so each one is 10 uh grams of
protein M and 50 calories and I will
have five of those as a snack there's 50
grams of protein right there with 250
calories like it's nothing okay what
about are they highly processed anything
to avoid there no problem because
they're made they're made by company
that I'm involved in so I mean I love it
the most obviously as a guy that only
gets involved with things that I care
about think are real so it's called Maui
Nei venis okay these are um this a type
of deer called Axis deer that are
invasive to the state of Hawaii and so
they're harvested there in the most
Humane manner fashionable which is what
allows the animal to be completely
stressfree so they're harvested by
sniper at night under night vision and
whoa yeah so if you think about it like
harvesting an animal is a very stressful
thing thing for an animal uhhuh like if
you're thinking about how a cow is
harvested yeah even if it has the
most um wonderful life you know it's
grass-fed it's out in a pasture it's not
inside like all of that might be great
and it is certainly better than the
alternative but the very end of its life
is still quite stressful this is a moral
thing or does this moral no I believe I
believe I believe it impacts the quality
of the meat right so think about the
cortisol levels that are surging through
that animal's body right at the time of
its death yeah but from an evolutionary
standpoint everything got eaten oh no no
I'm not that's not a moral question I'm
saying from a health perspective yeah
but I'm saying you're a lion the gazelle
you're chewing on is freaking the [ __ ]
out as you eat it alive so there's no
way that can have some major no I think
it actually probably has an impact on
taste more than anything else um the
other thing is it's very hard I mean
this is more of an argument of why I
love Wild game yeah is Wild game eats
the best plants the best feed right so
when you go to the grocery store and
you're buying you know a regular grain
fed steak it's not eating what it
evolved to eat like it's you kind of
want things that are as close to eating
what they evolve to eat and you know for
for for deer that's like that's
basically grass right so um anyway these
things are processed in a way that
basically has nothing in them right so
you're just I'm just getting pure
protein yeah I don't want to derail this
but this is really interesting so you
snipe the deer at night using night
vision goggles so it basically dies in
its sleep it dies instantaneous yep dies
instantaneously
stressfree um and that is so interesting
how'd you find out about these guys um I
met the founder of the company five six
years ago um and we just immediately
became friends I became completely
fascinated by the problem that they were
trying to solve which was how you know
the government is trying to eradicate
this species um because it is destroying
the island so this is a species of deer
that was brought to Hawaii in the 1950s
for hunting but it had no Predator it
was brought from India where its only
Predator was the tiger you brought it to
Hawaii it had no predator and it has now
run a mck so it is kind of destroying
three islands of Hawaii are they finding
a way to do this sustainably now so that
they can keep having them the goal is by
20 30 to have it be sustainable right
now they are still not able to do it
sustainably in other words right now the
deer are still growing at a rate that is
too significant
Jesus uh head shot yes interesting wow I
don't know why I find that so
fascinating but that's very interesting
okay so back to protein intake right so
point is you could have a w prot wake up
I'm like oh Chomp Chomp into the not
necessarily like I mean again it depends
on when you like to exercise for example
so so I should exercise fasted is that
the point of that um it depends if I'm
going to exercise first thing in the
morning I do it fasted if I'm going to
wait a couple of hours I'll have a
protein meal first but it doesn't matter
because I've always heard that you've
got so much glucose if you're eating and
now you're just going to get fat and you
never going to lose doesn't matter no so
so um I generally prefer to exercise
fasted but if the workout is getting
pushed till later a couple hours later
I'm going to have something before not
because I need to but because I want to
make sure I spread out those proteins
servings enough so at least two of my
protein servings aren't meals they're
like again the jerky is not a meal it's
a snack and then like a whey protein
shake again 40 50 grams of whey protein
in some you know cashew milk you do
would you uh I'm willing to stomach the
venison snacks Andor chicken breast
Andor eggs eggs yep great cool love them
uh so if I'm willing to eat the amount
of protein that I need in eggs venison
whatever would I still do a protein
shake not necessarily no not at all and
do you cuz I have developed slowly over
time a deep aversion to anything that's
processed so I'm trying to get as close
to biting into the walking animal as
possible absolutely y That's great okay
so but you you're not stressed and then
you would have like kind of two meals
right so I'll probably also have like my
lunch would be a salad with chicken
breast or salmon and then my dinner
dinner is the easiest meal to hit your
protein Target right like that's like
falling off a lot
just because it's typical to eat a steak
Chien whatever you're going to have talk
to me red meat white meat matter again I
think it matters less the color of the
meat matters much more the source of the
meat matters much more about how that
anal grain fed yeah and and how close
can you get it to an animal that's in
its natural state truthfully it's much
easier for me to get wild game that's
red meat like I much prefer elk and axis
deer both Wild game that either I'm
killing or someone I know is killing and
it's the wild that's the important yeah
it's an animal that's eating in the
environment it's it's an animal that's
not contained right and the contained is
problematic largely because of the diet
that we know they will need yep okay uh
how much meat how much of your protein
comes from meat by
percentage
um I don't know I'd have to figure it
out but clearly the majority H yeah
because the one thing I've always I also
like Greek yogurt by the way so that's
another thing that's a hard left so
Greek yogurt has a lot of protein it
does actually it's quite high in protein
eat it because of the taste probiotics
just another way to get protein in
diversify a little bit from boredom or
diversity matters yeah just some no no
just for me diversity matters like I
like to mix things up and and it's just
again it's just a function of time like
maybe I don't have time to make an
omelet right now and I'm I got a quick
call I got to jump on so I can scarf
down a bowl of Greek yogurt with some
nuts in
it this seems
impossible it seems too good no sounds
amazing like I feel like the way that I
live right now would take a lot more
discipline than what you're
describing be interested to see if
that's true in practice
um okay so let's fit eggs into the mix
here uh i' love to get an idea knowing
that individual there's a lot of
individual variability here in fact we
should probably talk about saturated fat
at the individual level the one thing in
my diet I do not at all pay attention to
how much saturated fat I eat and go out
of my way to consume it but I make zero
attempt to avoid it and because I don't
check my blood levels nearly enough I am
always a little hesitant to push my
exact diet onto people um do I need to
worry about saturated fat potentially
yeah um saturated fat can increase your
uh synthesis of cholesterol it can also
with enough of it being consumed the
liver can sense the amount of saturated
fat and basically shut down the
clearance of cholesterol meaning the the
the bringing of cholesterol into the
liver can I quote Peter AA on
cholesterol in the book outlive if you
haven't read it I highly suggest it he
said your total cholesterol number is
about as meaningful to dying from heart
disease as your eye color that's right
so you're bringing up cholesterol so
some something matters something about
cholesterol matters but not the total
number right total cholesterol is again
not particularly relevant number
apob which is the uh con which is a
measurement a laboratory measurement
that is the
concentration of lipoproteins that carry
cholesterol into arteries that's what
you should care deeply about but when
someone says what's your total
cholesterol 200 milligrams per deciliter
who cares doesn't mean anything but
there is a type of cholesterol that is
carried in a certain well so cholesterol
for the most part that 200 migs per lit
is your total cholesterol is divided
into three types of lipoproteins a high
each has a different carrier uh no that
200 comes is the aggregation of
approximately three lipoproteins high
density lipoprotein low density
lipoprotein and very low density
lipoprotein so if you look at your lab
you get you get a blood test done if
it's done correctly a lot of them are
not but if it's done correctly and they
do a direct measurement of LDL
cholesterol you will be able to add up
the V LDL cholesterol the LDL
cholesterol the HDL cholesterol and the
sum of those three will equal the total
cholesterol so if the total cholesterol
is 200 and the HDL cholesterol is 70 and
the vldl cholesterol is 20 the LDL
cholesterol will be 110 yep and of those
three
numbers um we would say the most
important Insight you could get would be
to take total cholesterol subtract HDL
cholesterol and that number is called
non-hdl cholesterol that number starts
to become a pretty good predictor of
risk so total cholesterol because those
are damaging in some way yeah that's now
telling you the total cholesterol
content of LDL and vldl and those are
the destructive
lipoproteins now an even better number
is not how much cholesterol is contained
in those two things but how many of
those two things do you have and that's
what's captured by
apob can you explain that more
so each of those
lipoproteins the vldl and the LDL have a
protein wrapped around them that protein
is called APO lipoprotein
b00 which is a very sexy name it's
abbreviated
apob so if you measure apob because LDL
and vldl have one and only one APO
lipoprotein b00 on them the apob number
is is the concentration of those two
particles and the gradient of that the
more of those particles you have the
incre the greater the probability that
those particles are getting into your
artery walls got it so the the number of
those do matter and so if I just
subtract out my HDL subtract your HDL
from your total cholesterol you get the
cholesterol concentration of those two
particles but but and that's predictive
of risk mhm but what's more predictive
of risk is the number of those particles
okay so which a how do
you I don't know if it's going to be
fruitful but there's something in that
math that I'm not following so if I got
back my cholesterol count and I look at
them I'd be able to tell of my 200 let's
say uh 110 are the two that are bad uh
but there's some total number it sounds
like you're it's a separate measurement
you don't you wouldn't impute it from
the those CL you just have to go to apob
you have to get the apob measured that's
right yeah it's another laboratory
measurement understood understood that
is unfortunately rarely done is it can
you just ask your doctor give me an apob
measurement absolutely okay it's a
relatively inexpensive test it's about
depending on the test it's somewhere
between and $20 do they not do it
because they disagree with you or they
just they don't know they don't know
what it is troubling very okay uh so in
fact we should talk at least briefly
about this idea so in the book you talk
about medicine 3.0 versus Med medicine
2.0 medicine 2.0 is all about curing
medicine 3.0 is all about
prevention
um how do we I would call medicine 2.0
more about treating than curing okay
fair it's largely not Curative right
very good distinction uh okay so if you
were going to give me the um the little
toolkit of medicine
3.0
uh what how would you begin to bundle
that like what are the the things
that I should be going towards well
again to your point so medicine 3.0
really says we've reached the limits of
what medicine 2.0 is good for medicine
2.0 is really good at
curing uh acute problems M so it's
really good at curing um infections
traumas acute issues it's really bad at
treating chronic problems MH cancer uh
you know current heart disease
neurodegenerative disease type 2
diabetes it's really bad at treating
those things and therefore all it really
does is prolong the period of time you
have those things and I go through a lot
of explanation in the book as to why
that strategy is not the right strategy
so living longer is not accomplished by
living longer with disease living longer
is accomplished by living longer with
out disease once you realize that you
inevitably come to the obvious
conclusion that a new type of medicine
is needed which must be focused on
extending the period of time you do not
have disease and that word is prevention
which has been bastardized to mean
virtually nothing because everybody
talks about prevention but it has no
meaning right so true prevention has to
start very early true prevention needs a
set of tools that medicine 2.0 doesn't
participate in medicine 2.0 which is the
medical system that every one of us
who's trained goes through is largely A
pharmacologic playbook now you're going
to get people who sit here and say are
all pharmacology is Bad Medicine is bad
no no no that's not true at all
pharmacology is wonderful pharmacology
has done amazing things in medicine 2.0
and we would want to use all of those
pharmacologic tools needed in medicine
3.0 but it's literally you know 1 of the
equation where is nutrition where is
exercise where is sleep where is
emotional health those things are also
needed to delay the onset of chronic
disease and none of us got trained in
those tools so if if a doctor is going
to help their patient with those other
four tools they're going to have to
learn about it outside of Medical
Training that makes sense uh okay so if
we know what we're trying to do is delay
the onset of these diseases you talk
about that in the book that basically
the thing that centenarians have in
common is that they probably were able
to delay the arrival of heart disease
dementia uh because you say this um
cancer that these things are building
for oftentimes decades that you can see
heart disease in teenagers y uh which is
pretty crazy so these are people that
have probably delayed the onset of the
early symptoms of that for decades more
than the people that died say 70 or 80
exactly okay that makes sense so now
then I want to get to and we'll stay on
cholesterol here for a second so uh you
talk about in the book that dietary
cholesterol does not equal cholesterol
in your body so what does what causes
bad cholesterol being the thing that I'm
certainly more concerned about so
dietary cholesterol is very difficult
for our body to absorb it has a bulky
chemical side chain on it called an
Esther and the only way we could absorb
it is if we have an enzyme to cut the
Esther off called the deesterified and
bring it in we don't have much of that
enzyme so most of the cholesterol you
eat such as the cholesterol in you know
shellfish or eggs you poop out M okay so
we should just make sure everybody
understands that eating cholesterol has
almost zero bearing on your cholesterol
levels in your
blood that doesn't mean that your diet
has no bearing on the cholesterol in
your blood but your genes play a very
significant role in the levels of your
blood lipids so we want to always
differentiate between cholesterol and
lipoproteins cholesterol is the cargo
lipoproteins are the boat H
so um the term bad cholesterol doesn't
actually mean anything people say LDL is
the bad
cholesterol that's actually very
inaccurate right LDL low lipoprotein is
the boat that carries cholesterol and
LDL is bad but we should really say LDL
is the bad lipoprotein the cholesterol
in LDL is the same cholesterol in HDL
which people call good cholesterol so
you can see why it doesn't make any
sense now every cell in your body makes
cholesterol
so 95% of the cholesterol in your body
is cholesterol you
made the reason every cell in your body
makes cholesterol is because it is one
of the most important molecules in the
body if you couldn't make cholesterol
you would have died in
utero um and the reason for it is every
cell in your body is wrapped in a
membrane and that membrane is made of
cholesterol most of the um important
hormones in your body testosterone
estrogen progesterone cortisol are made
from cholesterol so this hormone is
absolutely this molecule is essential
for life um but not every cell can make
enough of it so we have to be able to
traffic it between cells so we have to
be able to take it back to the liver the
liver has to be able to package it back
out it has to be able to move around the
system so if your body is like a big
city the Super Highway of that body is
the blood the circulatory system and the
circulatory system is made of water so
when you cut yourself you know you see
red stuff come out but don't let the
hemoglobin and platelets and things
confuse you it's just water with a bunch
of red proteins in it um and fat doesn't
mix with water cholesterol is a fat it's
a lipid and it doesn't dissolve in water
so we can't just move cholesterol around
in the blood the way we move glucose or
the way that we move sodium or potassium
those things are dissolving in water
they're called hydrophilic and they move
around freely cholesterol is not it's
hydrophobic it repels water so that's
why we have lipoproteins we have to have
these lipo proteins to move the
cholesterol in and out of the
body and that gets to the point of there
are basically these different types of
lipoproteins some of them are very high
density they have lots of protein and a
little bit of fat in them some of them
are low
density lots of fat less protein and
some are very low density virtually no
protein and lots of fat or
cholesterol and they have different
properties and it turns out that the low
density and the very low density ones
are the ones that are arthrogenic
meaning they're the ones that promote
the destruction of your
arteries okay so something is starting
to slowly come into Focus for me so fat
in the blood is bad cholesterol or fat
which one do you mean I mean fat so when
we talk about if if I'm understanding
what you're saying correctly there are
two times now that fat getting loose has
sounded like a problem uh well let's not
so so fat is rarely FL floating around
the bloodstream for the same reason but
if A lipoprotein if the very low density
is indicated because it has very little
protein and a lot of fat well just when
I use fat there what I'm really
referring to is triglyceride and
cholesterol but they're inside the
lipoprotein why do it matter that the
ratio of protein to Fat starts getting
low it only matters in that that's how
I'm describing why they difference in
density got it so it isn't that it is
fat that makes them problematic so what
do they do what's problematic is that
the low density lipoprotein and the very
low density lipoprotein are the only
ones that seem to make their way into
coronary artery walls or artery walls in
general and they have the potential to
get stuck in there so the high density
lipo protap thing no we don't really
have a great sense of it it's something
about apob so HDL high density lipo
protein doesn't have APO on its surface
it has something called APO a on its
surface and when a high density lepo
protein goes into the artery wall it
comes back out when AN apob particle
goes into the artery wall sometimes it
comes out but sometimes it stays in
there and when it stays in there or gets
retained bad things begin to happen the
first of those things is it undergos a
chemical reaction called
oxidation that chemical reaction called
oxidation creates an inflammatory signal
and that tells inflammatory cells called
macroasia or monocytes to come they
become macrophases and they eat that
oxidized LDL
molecule that's what kicks off a
devastating Cascade in which the body
ironically and paradoxically in trying
to fix the problem creates a
catastrophic problem that ultimately
leads to the creation of a plaque that
if it ruptures will block the blood
supply of the artery and cause a heart
attack you've got the two types that end
up basically they have the apob on them
apob can get stuck in my arteries once
it's stuck in my arteries my body sends
a immune response effectively that then
ends up creating a problem uh is that
Cal ification calcification is the final
stage of the body trying to repair the
problem okay so think of it as the
concrete that gets poured on a melting
down nuclear reactor so when you get a
CT scan that's like what's called a
coronary CT scan to look for
calcification the presence of that
calcification while by itself not
problematic is predictive of something
bad that's happened I describe I think
in the book calcification is like going
through a neighborhood and seeing bars
on the windows the bars on the windows
are actually a good thing they're going
to prevent somebody from breaking in but
it tells you what kind of neighborhood
you're in yeah okay now that makes a lot
of sense going on with my diet one thing
that I'm very curious about and there's
a raging debate online a cal is just a
calorie
um where where do you come down on that
in terms of the quality of the calorie
does it matter U if I'm eating ter like
if you agree that the quality of the
calorie matters but I'm still undere
eaing do I have a
problem so the the the calorie a calorie
discussion always needs some
clarification are we talking about with
respect to energy balance are we talking
about with respect to nutrition and
health are we talking about with respect
to
satiety and and so we have to clarify
which of those we're talking about all
I'm talking about ever is longevity
so so then a calorie is not a calorie
for sure right so in other words if you
took a bunch of people and put you know
one group of them on 2 200 calories a
day of Twix bars and another group on
2500 calories of you
know one food only lettuce you know or
whatever it wouldn't be 2500 calories
lettuce but you know 200 calories of
venison sticks venison sticks and
another group on 2500 calories of some
well-rounded diet that's you know you
know blah blah they might all end up
with the same weight they might have a
different Health Quality and they I
would expect it I clearly don't expect
the guy on 2 200 calories of Twix bars
to live as long as the person on 25 200
calories of good food nor do I expect
them to feel the same so if you're
totally and by the way they might end up
at slightly different weights because of
how they feel and while you may in this
experiment control only their intake you
might not be able to to control their
energy expenditure so they might
actually expend different amounts of
energy because of how they feel
so um the the calorie as a calorie
debate I think is kind of a silly one
because a lot of times people are
talking past each other when they're
yelling at each other and they don't
understand what they're talking about
and so you you know we just have to
understand are we talking about pure
controlled you know calorimetry or are
we talking about in your case what
you're asking about which is I think
more important which is
Health we are um innately really really
bad at estimating risk and oddly enough
makes me wonder about you and race cars
so what is it that draws you to race
cars do you think you're accurately
assessing the risk on that I I I will
say you know that's not an unusual
question I get asked a lot I I think
that I feel safer in a race car than I
do in my street car really absolutely I
feel far far more frightened in the
drive I have to take tonight from here
to San Diego because I'm going to be on
the 405 and the five and I know that 80%
of people at some point on that drive
are going to be checking their phone or
losing focus or not paying attention I
don't know what percentage of them maybe
10% of them are also going to be under
the influence of alcohol and uh they
pose a infinitely greater threat to me
than I I feel like I could ever face in
a race car so other than driving what
are some just grotesque misjudgments of
the risk in terms of behaviors that
people do just on a daily
basis um I think I think Automotive is
is a very big one so yeah good that we
got that one first I think another one
that people sort of
misunderstand
is
alcohol you know I mean I I enjoy
alcohol as much as anybody but I don't
think people understand how once you get
Beyond one to two drinks like how
harmful it is on your liver
and it's sort of like Tylenol right like
at any dose Tylenol is really hard on
your liver but for most of us because
Tylenol has no good feeling associated
with it we don't really tend to use it
more than we should we you know if we
have a headache we take it and it makes
the headache go away and but but we
don't find ourselves like taking four
Tylenol every day just because of
whatever reason and yet I'm I'm
constantly amazed at how much people
drink even when there's no apparent
reason for it right so so there's always
a reason to have a drink right there's
there you can always come up with a
great reason to have a drink but there's
too many sort of blah reasons that
people are drinking so I think that um
that that to me is an asymmetric and
unnecessary risk meaning the pleasure
that they're getting from that you know
those four shitty Budweisers that they
have isn't anything worse the potential
downside it's causing in the long run
which says nothing by the way of how
often I think people do get behind the
wheel of their car when they've had a
drink in them and if there's one thing
I've learned in the simulator it's how
even one drink compromises your ability
when it matters so I remember simulator
a driving simulator yeah so I have a
driving simulator at home which is where
I do much of my learning um but I
remember one day I was like yeah I was
going to go drive the Sim after dinner
and I had a glass of wine with dinner I
remember getting in the simulator and I
was like what in the hell is wrong with
me here like I am missing every Apex my
I'm just a little bit off I'm a little
bit off and I realized oh I had a glass
of wine even one glass of wine is
compromising me um so how many times
have I gotten a car having two glasses
of wine at a restaurant the answer is
tons was I legally drunk no I was well
below
008 but if even if I'm 006 I'm legally
fine is that still a reasonable strategy
right and I think the answer is probably
not you think there are dietary things
that people are doing that have just an
asymmetric risk reward yeah you know I'm
probably kind of a a huge advocate for
caloric restriction um at least
intermittent bouts of caloric
restriction so I believe that the
short-term discomfort of not eating for
days once twice four five times a year
going through a cycle like that I think
that the
shortterm inconvenience of that that
is Trivial compared to the potential
benefit of of a true fast you know water
only fast for some period of time and I
still don't know what that minimum is I
think it's probably a minimum of three
days are necessary to start to get some
of the real benefits of autophagy
mitophagy and things like that but
what's the difference between autophagy
and mitophagy um autophagy is the cell
eating itself and mitophagy specifically
is the recycling of the mitochondria
okay
um so I think when someone says and I
have many patients or friends or family
members who have said like yeah that's
just there's no way I'm ever going to I
could never give up food even
transiently I
think that's that's that comes from like
not not even being willing to give it a
shot like what's the
emotional hangup cuz you were you used
to be literally the epitome of the
robotic eater just insanely strict and
you said about 3 years ago you were like
nope not doing that anymore and I think
to quote you exactly I no longer have
the intestinal fortitude to eat like a
robot so there was something in you that
it no longer was worth it yeah that
became much harder than what I do today
which is so so back then I wasn't doing
any Tim restricted feeding I wasn't
doing any fasting it was is a pure form
of dietary restriction so my my sort of
mental model for nutrition is everybody
is starting out on one side eating the
standard American
diet abbreviated as sad which is an
appropriate
abbreviation and the thing I always tell
patients on day one is like look the
good news is you can't get any worse
than this the only thing if you're
starting at the sad the only thing you
can do to make it worse is eat more of
the sad right but it's like the standard
American diet and I don't believe this
was deliberate right I don't think
there's a conspiracy theory here but
just through a lot of bad
luck uh has arrived at the absolute
worst combination of macronutrients you
could possibly imagine like you couldn't
come up with a way to confuse someone's
metabolism than to combine fats and
carbohydrates in the ratios that they
are combined in most of the foods that
we would eat by default if we were left
to our
brothers so from there I say look
there's kind of two introd Rory moves
which are not mutually exclusive but you
can pick one or the other the first is
time restricted feeding where now you
don't limit what you eat you just limit
when you eat it and then the second is
dietary restriction you don't restrict
when you eat you don't restrict how much
you eat which you also don't restrict in
time restri feeding but you restrict
certain elements of what you eat so for
those three years that I was on a
ketogenic diet which is I mean probably
one of the most demanding subsets of
dietary restriction
um you know I'd pulled that lever as
hard as it could be pulled then you move
into diets that sort of mimic fasting um
which is basically just another way of
saying hypocaloric diets for transient
uh periods of time and then ultimately
even beyond that is fasting just you
know water only also for limited periods
of time nowhere in there do I
include constant caloric restriction so
you know reducing by 20 30% your energy
intake in definitely I I think the data
are pretty clear that that is not a
winning strategy there's something about
the cycling into and out of catabolic
versus anabolic State you're basically
Clearing House right you're sort of
getting the cells that are themselves
defective and hopefully the ones with
the most effective mitochondria we'd
love to Target those the most for other
reasons um what you want to see is the
regrowth you want to when you refeed you
want to see The Selective repopulation
of the better cells the most robust
experiments done on this in primates did
not really suggest that as the diet got
better the benefits of caloric
restriction got better in other words
the worse the diet the better the
benefit of caloric restriction which
points us to this idea that dietary
restriction should still always be some
component of a healthy nutrition
strategy meaning like if you're eating
like [ __ ] stop eating like sh stop
eating you really really if you're if
you're committed to never eating
anywhere but McDonald's caloric
restriction will have a much bigger
effect on you positively than you know
if your Baseline intake is you know the
way you would eat for example that kind
of stuff at like the Deep cellular level
about where we're going and what this is
going to look like is is really
fascinating to me definitely not
something that I have the kind of grip
on even remotely close to what you do
but nonetheless seems like if you're um
really going to get to 100 at a high
level it seems like you're going to have
to take that pretty seriously now you've
talked a lot about
one of the tests that you want to make
real is the ability to check for
autophagy and to see in the blood um
you've thrown out a couple times that
this is like a you probably know the
people that would be creating this test
um and B that it wouldn't be you know
it's not measured in the billions so
what what would that really take um is
it something that could be
commercialized and would give people the
impetus to put the capital up for it or
what does that future look like from a
funding perspective again this is not
not like the world's hardest problem to
crack um but I'm if I'm going to be
completely truthful I don't know how
commercially interesting it is as a
general rule diagnostic tests are not
very commercially interesting um my
interests are not remotely commercial my
interest is in just knowing what to do
it's like I want this test to tell me
exactly what the right fasting protocol
needs to be should I be fasting 3 days a
month 7 Days Every 3 months 14 days when
once a year like I want to know that and
there's no amount of money that would
make it worth you know not knowing the
answer to that question um wow that's a
bold statement well think about it and
I'm not to suggest that like money
doesn't matter and money you can't do
great things with money like I want
money just as much as the next person
but never at the expense like I don't
want anything to get in the way of the
knowledge that can drive living longer
that to me is such a priority that I
would rather be
poor but know how to you know live
longer than have all the money in the
world and lose my health I totally get
that but I will say one thing I want to
talk about is you said that um one
you've said that you think that you eat
dysfunctionally even if you don't have
an eating disorder which I actually
thought was really interesting and then
you said that part of why you gave up
the robotic eating was you were worried
about how it's affecting your daughter's
view of food talk about that CU I think
certainly in this the movement that
we're all going through right now
there's a real risk of that that if I
had had kids 5 years ago when I was like
ter I was shredded I was so myopically
focused on everything that went in my
mouth and I loved it about myself and I
would Rave about how much discipline I
had so for sure if I had kids they would
have been wildly influenced by how much
pride I took in not eating and so yeah
do worry what that would have done and I
thought it was super sensitive of you to
recognize that and change
yeah I mean my brother um actually was
the he he brought this point to my
attention first but he said you know be
thoughtful about how you describe your
own interactions with food and when
you're giving you know your kids input
on what to eat or what not to eat try to
tether it less to you know body
dysmorphic ideas and Trigger it you know
Peg it more to Performance issues for
example right because those things are
still true right if you if you eat well
or eat poorly it affects your
performance it affects your cognition it
affects a lot of things um and if the
focus is more on those things then then
you know sort of daddy why aren't you
eating this because I don't want to be
fat well you know that's and and look
there's a truth to it like I mean I'm a
vain person I I I'm not you know I've
come to a place where I've accepted the
fact that I can I won't look like I used
to look like cuz I'm not willing to put
in that amount of sacrifice ever again
you and I have the luxury of being old
enough to be able to think through that
in a slightly uh less emotional way and
at least make that make that choice when
I think people who are
younger um I don't know I just don't
know if they're equipped fully with the
tools to make all of those decisions I
want to ask you about change you have
changed a lot in your life like multiple
times from starting out and getting your
degree in um engineering and Mathematics
and then ultimately pulling the first
Switcheroo over into to Medicine then
leaving medicine and becoming a
consultant then going into hardcore
research and um doing uh nonprofit work
and then now back to Medicine what what
has allowed you to constantly make those
jumps or what propels you to make those
jumps I have been able to internalize
something that I think is not innate to
most people which is the fallacy of a
sunk
cost so uh the sunk cost fallacy is
something that gets talked about in you
know any Econ 101 class right so you've
uh you know you're you're building a
bridge and the you know the cost of the
bridge is $10 million and you're $9
million into it and the contractor says
Ah it's going to be another1
million um for many people they are
evaluating that based on how much money
they have already put into the project
and that becomes a very dangerous game
because you can't get those dollars back
so instead you have to evaluate it from
the standpoint of exactly where you're
standing at that moment in
time and for whatever
reason
I've I've been able to stand at any
point in my life and sort of say I want
to do X I'm going to evaluate that only
through the lens of how many years do I
have left on Earth and not at all
through the lens of what have I already
put into this um
and I think that's just made it easier
to do things that on the outside look
odd look orthogonal and then to leave
medicine um whatever it was 12 years ago
that was something that a lot of people
came to me and said you got to
reconsider this like you've put far too
much into this and I just said like look
I'm going to do something for the next
40 years I want it to be exactly what I
want to do and that's way better to me
than saying well I'm going to do
something that I don't really really
want to do because I've spent the last
10 years doing it which is where I was
i' put 10 years into medical school and
training um postgraduate training and it
was like look that's that's 10 years I
can't get back um and it's that's a
fraction of the time that's still in
front of me so just it just seemed very
logical to me to always pursue my Bliss
um and also I mean going back to
something you said I think we're in a
different world now I mean I think the
days are long gone of you do one thing
for your whole life I mean I
think for some people that will be the
way to do it and that's that's great but
it's no longer so ridiculous to have a
career change every five years I
don't I don't know what I'll be doing in
10 years but I'd be shocked if it looked
exactly like what it looks like today
like I think you know if you're not
growing if you're not constantly being
reminded of how much more how much
higher you have to climb um I suspect
it's I suspect life becomes a lot less
fun what drives
you I mean truthfully I wish I could
come up with a whole bunch of pleasant
you
know sort of nice things to say I think
in reality unfortunately a lot of my
drive is
insecurity um that is shocking
and I've heard you say that before um
and the first time I heard you say it I
thought that's really fascinating
because you're somebody who gives me
insecurity so the fact that you feel
insecurity is pretty fascinating and so
as a driver in what way does that drive
you David Foster Wallace said in in what
what is unquestionably my absolute
favorite 22 minutes than one could ever
listen to which is his commencement
speech from 2005 called This is water so
and and the first time I ever heard this
it didn't resonate with me I needed to
hear it a few times before it really
resonated where he
said if I if if you if you worship power
you will forever feel
powerless right and and that doesn't
really resonate with me because I'm not
a power Seeker but I absolutely worship
intellect and and when he with the next
words out of his mouth are you will
forever feel like a fraud I'm like that
is so true I find find myself at least
on a daily basis
thinking dude I hope people don't find
out how much I don't know wow and and I
wish I wasn't saying that I mean I wish
I could I really wish I wish I could say
all of my motivations are pure it's all
I'm you know I'm Mother Teresa I just
want to fix every problem and make the
world a better place but the reality of
it is like I think a significant amount
of my motivation is just this complete
desire to not be found out as a fraud
who doesn't know stuff I love that for
two reasons one I think that and I'll
speak very much for myself from the
moment I met you I was like this guy
[ __ ] with my head like there's just
certain people where I'm like I it's
hard to feel smart around you so the the
fascinating thing is you know to hear
that uh that there's some of that
driving you um and then two hopefully
people listening to this that that um
aren't comparing themselves to you but
yet are looking at you going this guy is
[ __ ] fast fascinating I'm really
interested and they have like a warm
feeling for you uh that's probably equal
parts like oh he's compassionate towards
humanity and that's rat and then equal
parts like wow he's [ __ ] smart that's
you know he's got cool [ __ ] to say and
so for them to hear that you can be so
um open and honest about oh yeah I have
insecurity and um it's low self-esteem
that's pushing me forward because they
they will look at you and think it
impossible that you could possibly have
have low self-esteem um which I think is
really really good for people to see
that that never goes away and one of the
things that I've always thought was I'm
not going to call it a superpower but
something that I've been glad that I
have for myself is my motives are always
apparent to me even when they're ugly
and Petty and yeah I mean there are
times where like what's driving me for
whatever reason is ugly it's Petty it's
um makes me feel worse about myself
whatever but at least I have Clarity on
what it is yeah I wish I could say I
always could see it I don't think I can
I think it requires a lot
of I I don't think two years ago I could
have
acknowledged um what I can be much more
brutally honest with myself about today
what happened that made that I mean you
know I've always seen therapists my you
know there's been very rare has there
been a season in my life where I wasn't
sort of searching for some sense of you
know
why do I feel so tormented
and you know one of them said the most
insightful thing to me I've ever heard
you know your entire life your entire
life has been basically driven by um
three skills three things that you do um
that you're really good at and they're
not good things by the way right
emotional
Detachment rage and obsession wow you
those are like the only three tool you
are a guy that has a toolbox that has
three tools and those are the three
tools and she said look you've got a lot
of good stuff out of those tools there
are a lot of people who get those three
tools and they just end up in jail so
you've managed to through a lot of luck
um you know wind up not in jail wind up
as a quasi successful human being a
contributor to society a father like
you've done some good stuff but she also
said you're sort of at the end of your
rope with those three tools like you
can't get any more juice out of
squeezing those things there is no
combination of emotional Detachment
Obsession and rage that is going to
produce anything of value and you're
actually now at the diminishing part of
the curve so now you're actually you're
regressing so you're going to need new
tools and you know so in many ways I
think that's what has allowed me to go
back and say okay well what what is the
impetus of that why is the why are these
things happening what you know who do I
want to be in five years right because I
can't fathom what I like I can't fathom
being any different in five days so I
have to think bigger I have to think of
like okay in five years you want to be
it's sort of like what we talked about
at the outside if if when you're 100 you
want to be able to do these things you
can back out of that and say this is
what you have to be able to do when
you're you know 70 or 60 and similarly
if in five years when my kids are aged
this this and this I want to be this
kind of a
person and right now I'm not on a path
to be anywhere near that in fact I'm on
a path to be completely different you
know complet different place okay so
start backing out what the person who
can do those things in 5 years has to be
able to do what in a month how would
they react in this situation versus how
do you always react in a situation
people like me who are very good at
doing things where harder work produces
better results like when that's your
playbook and you are now confronted with
trying to do something where that
Playbook doesn't work it is ego
demoralizing right like if the answer is
just swim further like all you have to
do is just keep swimming don't stop
swimming I got it like I that is my book
man but if the answer is no you now have
to be able to control your emotions in a
certain way you now have to be able to
as you said recognize in a
moment when you have an emotional
reaction why it's what it's really about
because it's never about what you think
it's about it's about something else can
you stop yourself in the moment and
recognize that
that is a new skill and I'm a baby
trying to learn that skill and my old
trick of just work harder just work
harder it fails so in many senses it's
like the most intimidating thing I've
ever tried to do right what's your
process in all this like how are you
actively getting better one is just
showing up every day right so it's like
you know the last time I last week when
I was the last time I spoke with one of
these therapists I just had a really
miserable day I mean I just didn't want
to talk to them at all
you know I was in a really really bad
mood and so part of it I guess is you
set yourself up around people who are
never going to take your [ __ ] right so
you have therapists so for me having
these these collection of people around
me it's like they absolutely positively
don't let me get away with anything you
know I guess part of it too is just
having really patient people around you
because you're going to make a lot of
mistakes in this process right so you
have to you know in my case I feel very
fortunate I have a spouse who is uh you
know I I would say more forgiving than
probably she should be she believes in
the in the sort of like this is what you
could be in 5 years this is this is the
guy you can be so when someone believes
in that they're much more willing to
help you when you fall they'll pick you
up as opposed to point out that you fell
and do you have like a specific vision
of yourself that you're building towards
or chasing
I mean I do
um and it's not it's not a professional
version of me it's a personal version of
me if I get wave a magic wand what kind
of a husband what kind of a father am I
and the reason I use those two as an
example is it's unfortunately the people
who are closest to me who always see the
worst of me and so most of what I think
about is how do you uh how do you show
up for those people CU if you can show
up as the best version of you for those
people the trickle effect is everyone's
going to be fine like you will be a
great version of you with everybody so
it's it's less
about how do you show up at the TSA
check gate when the person's obnoxious
I'm not I don't worry about that that
much that that's a relatively easy thing
to control but when you're taking out
your problems on your kids or on your
spouse you know to me that's that's the
stuff that's just got to stop and um and
if you can get to that to me that's like
the that's the hill of the mountain
that's like like that's the hill when
you climb that well at that point you're
going to be treating everybody the way
that they deserve to be treated
including yourself by the way I mean as
you probably know um those of us who are
the biggest you
know sort of jerks to others are usually
jerks to
ourselves you're quite aware of how hard
you are on other people when they make
mistakes do you realize how hard you are
on yourself look do you know what your
selft talk is when you're making errors
and and I started paying attention to it
and I was like wow that's really that's
harsh that's very harsh that you would
that you that you think these things of
yourself which again it all CES back to
this insecurity and at the outset I I I
said
um you know whatever five years ago or
four years ago 90% of my bandwidth was
on like how to not die and today that's
only 50% of my bandwidth the other 50%
is the whole physical stuff we talked
about and then it's this right it's this
um what does an examined life mean and
is it a life worth living um
because you
know I I do think we suffer so much in
our own heads uh more than we suffer any
any other way
[Music]
um and I don't know the answer to that I
here's what I know I know that that's
way harder than reducing the risk of
heart disease
um I know that's way harder than you
know addressing that is way harder than
fasting or doing all of these other
things that are even non pharmacologic
interventions that I think can fix all
those other things and certainly for
someone like me it's harder than you
know exercising or being disciplined
about all these other things um and I
suspect in part because it's less
amenable to doing right right the things
that we do um tend to be a little bit
easier but this is this is tough stuff
so I don't know may maybe part of the
reason to want to live longer is to just
give more Runway to figure this out
effectively why would you want to live
longer if you're
unhappy and that's such a obvious
question and yet I am
amazed absolutely amazed at how much I
interact with people because remember
all I do is interact with people who
want to live longer that's my job
everybody I'm talking to everybody who
wants to talk to me always wants to talk
about how to live longer how to live
better in some way and yet very rarely
are they paying attention to this aspect
of their life what is their relationship
like with themselves how well as you put
it do they understand themselves what
are their relationships with other
people how well are they able to
regulate their emotions how present are
they what is their sense of purpose what
is driving them all these things and if
that house is in
disarray I would make the argument that
living longer is a curse it's not a
blessing it's a bold
statement but push back on it I mean
what's the what's the definition of
torture right let's let's play a thought
experiment if I said to you
Tom I'm going to Grant you
immortality in perfect health so it's
not going to be like tonius where I let
you live forever but you age forever
that would be hell no no I'm going to
allow you to stay right like you are now
you're not going to get one more wrinkle
on your face you're never going to get
disease would you take it yes I'm not
going to give it to anybody else in your
life oh yeah I would take that I'm
always shocked that other people my wife
included wouldn't I would all right so
so let's go one step further I'm going
to give it no I wouldn't that's so
interesting do you know how many people
you're going to watch die wait I'm
making the Assumption that's what
bothers you why wouldn't you take that
um well let's come back to me I want to
keep going with you for a minute okay so
now I'm going to make the I'm going to
give you a different experiment we're
going to do the same thing but I'm going
to put you on a desert island now yep
and I'm going to provide everything for
you MH so you're not going to have to
worry about finding food um in fact
forget the desert island I'm going to
keep you in this beautiful house yep and
I'm going to somehow keep the lights on
and I'm going to somehow keep the food
coming in but there will be no other
human on this planet for you to ever
interact with including your wife would
you take that can I kill myself no so I
have to live forever like that yes
that's the first one where just what I
know about the human psyche breaking in
isolation I I it would be ill advised
though God I would want to if you'd let
me kill myself at any point I would take
it but if I can't it's too dangerous no
of course you wouldn't take it right I
mean you how it's not in a course for me
that is not self-evident and if I didn't
understand what happens to the human
psyche when it's isolated in in my life
where I have been isolated for extended
periods of time I have experienced no
suffering
whatsoever I don't disagree with that
but I think the question is yeah what's
the longest of time you've been isolated
yeah exactly and what does isolated
truly mean yeah yeah yeah and if I have
input like if you let me keep the lights
on and I could have entertainment I've
thought a lot about this like uh how
much would that help but like let's you
saw the movie cast away yeah okay so if
I had any glimmer of hope that I could
get off that Island I would want to be
alive I would want to try and try that's
a totally different story right so this
is what I'm saying is even the hope that
I could one day reconnect I'm telling
you there's no hope I'm telling you I'm
going to let you live indefinitely in
this house all by yourself y okay so
that's just an extreme example of one
dimension of emotional health which is
connection to others and I'm I'm telling
you that given everything to excess oh
and by the way I'll even I'll even
sweeten the deal Tom I'll give you all
the money in the world and you can buy
whatever you want wow right now buy what
oh you could buy Yachts art whatever you
want we've we're going to have robots
that do everything for you that that
make everything and you can't interact
with these robots going to say you you
complicated the robots are not they're
not going to supplant so there's there's
everything I could ever want except for
you have all the cars all the Yachts all
the whatever you're not going to do it
if you really stop to think about it
you're not going to do it because with
no connection to another person it's a
meaningless life yep so we could do the
same sort of exercise going through all
of these different elements of emotional
health and I think if people are really
being brutally honest with themselves
they'll realize that if you you know if
your wife hates you if your kids hate
you if your you know you're if people
around you don't feel good about you and
you don't feel good about yourself and
you're not you know you don't have a
sense of why you're doing what you're
doing I think I think it's a I think
it's a tough I think it's a tough way to
live so it do you think that people
asking that question of how to live
longer is in some ways not the wrong
question but it's just so
incomplete that you need to address
the emotional
side I think it's a very understandable
question um I can't speak to others but
I certainly through my own experience
can understand why one would ask that
question and why it's something you
would want to grasp on to I mean I think
that for most of us the thought of not
existing is a
little um if not frightening certainly
very uncomfortable H non existence is
very
difficult only on the back side so we
all know what non-existence is like try
to imagine what you were like before you
were born so I don't I it's possible I'm
deluding myself it's also possible that
I really just see this slightly
differently so I have absolutely no fear
of not
existing
if yeah the thought of just not waking
up tomorrow only gives me anxiety around
ooh did I make sure that I sort of
things out for my wife like is she going
to be okay like the thought of something
bad happening to her I don't like that
um knowing that I'm about to die would
change my frame of reference so
radically that it would make me
immediately behave differently so
definitely a huge part of the way that I
behave is predicated on that I have more
time I try to operate knowing that it's
certainly not guaranteed I could have an
aneurysm and Keel over and dive before
the end of this podcast uh I'm very
aware of that um
the reason that this feels so important
to me and the reason that I was so glad
you included it in the book is that I
think the only thing ultimately that
matters is how you feel about yourself
when you're by yourself and if you have
earned your own respect I think that's
hugely important just found it very
intriguing that not a lot of people are
going to cover that topic in your book
and I was wondering if there is if it's
just that like hey make sure that that
it's worth fighting this hard to stay
alive and make sure that you're not just
driven by the animal instinct to fight
or flight and basically you have a
vision of your mortality that you're
running away from but you're never like
figuring out why you live or is there
also a sense
of if you're in that state where you're
very stressed out you're prone to anger
whatever the case may be you're also
shortening your life yeah I think it's
both Tom and I think that a lot of
people are self-sabotaging without
understanding why
so we have a lot of agency over living
longer I mean if there's one thing I
hope someone takes away from this book
it's how malleable their lifespan is and
how malleable their health span is but
you have to do things to get that as you
pointed out at the beginning of the
discussion there is no easy way to do
this um there's not a pill or a specific
workout or a superfood or a supplement
or whatever that's going to make all of
this easy it's a lot of stuff that has
to be done over a relatively long period
of time and your ability to do that is
highly predicated on your relationship
with yourself and so you know having
sort of poor sleep habits poor nutrition
habits poor exercise habits on some
level has a component or a root in your
emotional
health and that's not true for everybody
but it is true for a lot of people uh I
and I see this constantly in my patients
right I see patients whose Own Story
whose own narrative is partly an
impediment to their actions and so
they're suffering twice they're
suffering in that their failure to take
action or their actions that they're
taking for example drinking too much are
going to actually shorten their life but
they're also going to um decrease the
joy of their life and the harmony of
their life for whatever period they
have so let's say that we do everything
right let's say we've got meaning and
purpose We have dealt with our emotional
difficulties we have identified and this
is actually something that's really
important that I took away from the book
you really have to figure out what of
the horsemen is coming for you what
agent of death from uh family history
genetic makeup lifestyle all of that
which one is most likely to come and get
you I think that's very important it
might be worth actually recapping who
the horsemen are we've touched on them I
think all of them but we didn't name
them as like these are the horsemen
might be worth doing that um but so
you've you're doing all this how long
can we live like is it really like we're
already there it's like 122 and and I
hope you get there my friend and follow
the book and you'll get to 122 to or can
we actually push this farther based on
what we have today I don't see us
exceeding the human record for longevity
I think to go beyond that would require
a technological breakthrough so I would
never represent that you know doing
everything to the max with respect to
perfect nutrition perfect exercise
perfect management of the horsemen
through all means necessary that that's
going to get someone to exceed that
level um you know
my thinking of this is that you know we
might have 10 years of
stretch um which is a huge amount if you
really stop to think about it right if
your you know life expectancy is 82 and
you make it to 92 instead in their
quality exactly and that's the point
right where I'm really confident we have
the capacity to change it is on quality
MH and you know I said to you everybody
comes to me on some level and they want
to talk about longevity but when I
really probe them what they really mean
is Health span they don't care as much
about how long they live they really
care about the quality at the end of
their
life I care about both be really honest
as do I Health span would be if I don't
have that it's all meaningless I totally
agree with you um I would pay all almost
any
price to live longer and so the for
instance um the question that that uh
you asked like I would even if there was
an apocalypse as long as there were some
other people even if it killed everyone
I knew and loved which would be brutal
man like I am I am into my wife in a way
most people just are not into their
significant other I can tell by talking
to them and even that I would if a
meteorite hit and it was like your your
wife is going to die but you can live
I'd be like yeah I want to live so my
wife wouldn't though she's like if you
die I'm going that's so interest I can't
rep my head I mean depends on my kids
but but yes if my wife and kids were not
on this Earth I wouldn't want to be on
this Earth what would happen if God
forbid Peter God forbid I don't have
kids because partly because I am so
afraid of how devastating it would be if
they died but if they
died would you want to
die um I mean again I I hope I never
have to contemplate that but if I lost
all of my kids yeah I'd have a hard time
probably wanting to go on Wow Wow I get
it man look it's it is I I have seen
people go through it it is an unbearable
thing that I can't believe life asks of
anybody but despite knowing how bad that
hurts and I would not want to go through
it I don't know man and and look of
course I might get so rocked I'm just
saying here from an emotional sobriety
standpoint where it is just the thought
exercise um I don't understand people's
response to be like yeah just take me
out but let's go back to I think what's
the more Germain point which is um you
want quality of life and length of life
I hope what comes across really clearly
in the book is those are not mutually
exclusive and what I really would like
people to understand is if you pursue
them both you get them both in fact if
you just focus on health span if you
just focus on preserving cognition
having the most physically robust body
possible as you age and pursuing
emotional health you are guaranteed to
get lifespan benefits as
well okay so talk to me about the
horsemen let's name them so there's four
three of them basically account for the
majority
of death in the uh first world one of
them directly doesn't account for that
much of the death but but indirectly
probably accounts for the most of it in
other words it's the amplifier of the
other three so the big three are the
diseases of atherosclerosis so heart
disease and stroke second one is cancer
third one is neurodegenerative diseases
inclusive of all dementias so that
includes Alzheimer's disease uh
Parkinson's disease Louis body dementia
vascular dementia Etc so those those
three really they they show up a lot on
death certificates they kill a lot of
people
the fourth one is more of a spectrum
it's not a single disease but it's the
spectrum that goes from hyperinsulinemia
to insulin resistance fatty liver
disease all that metabolic stuff we
talked about all the way out to type two
diabetes and again not a huge number of
people's death certificates as Naf D
type 2 diabetes a little bit but not not
staggering but when you're on that
Spectrum the further you get towards the
type two diabetes side of that Spectrum
you're just doubling your risk
essentially of all the other three
Horsemen do you think that metabolic
disease is causitive like is basically
every non um traumatic death is it
Downstream enough no it's it's it's uh
it's neither necessary nor sufficient
but it is causitive so so you can have
causality without necessity and
sufficiency so let's take an obvious
example smoking is smoking positively
related to lung
cancer 100% like meaning there there is
a causal relationship between smoking
and lung cancer but 15% of people who
get lung cancer never smoked I don't
know the number but many people who
smoke don't get lung cancer so similarly
metabolic disease is 100% causally
related to the other diseases but not
everybody who gets met not everybody
who's metabolically ill is going to
necessarily succumb to those diseases
you could die of something else um and
not everybody who succumbs to those
diseases had metabolic disease okay
that's really interesting there's at
least one example you give in the book
I'm not sure where you put your own
story but you scored a six on the
calcification uh scale very young 30
something and then anahad Connor who we
bizarrely both know you know him way way
way way way better than I do but I had
the Good Fortune of meeting him um he
scored like 126 or some ridiculous thing
so is that the kind of example where you
guys were both relatively healthy but
have this this what genetic
predisposition well totally different
issues I mean anahad as I wrot about in
the book had unbeknownst to him a very
elevated LP little a um which is genetic
and he was otherwise exceptionally
healthy um and is to this day
exceptionally healthy but had this
genetic issue that was
driving you know rapidly advancing heart
disease and luckily um you know was
caught really early I mean 125 or
whatever his calcium score was pretty
darn Advanced but to be able to catch
that at such a young age uh is is going
to make an enormous difference in course
correction so had he not had that
calcium scan done and acted on it uh
there's virtually no question in my mind
he would have died prematurely yeah so I
was going to ask so if that isn't a
driver or isn't being driven by his diet
is it purely just genetic look of the
draw yes okay so in the book you tell a
story of somebody that came to you they
had just the worst deck of cards or hand
of cards that you could be dealt around
uh cognitive
decline well as in the they had the
worst I mean they didn't have the worst
fortunately they had you know a very bad
hand dealt to them Visa the risk of
Alzheimer's disease so how do you if you
get a rough deck hand why I keep calling
deck you get a rough hand like that uh
what do you
do um you start acting as early as
possible possible to mitigate the risk
so we know what one we we have a really
good sense of things that people can do
to reduce the risk of Alzheimer's
disease and in this particular woman's
case I call her Stephanie that's not her
real name um we we undertake a number of
things uh with respect to sleep stress
uh nutrition exercise supplements that
we know are correcting certain
deficiencies such as elevated
homosysteine levels um and
unfortunately in her case fortunately
because she's so young but unfortunately
for many people we don't have
pharmacologic strategies yet so we're
just I think on the precipice of sort of
some Precision medicine ideas so for
example in our high-risk patients who
have this Gene the apoe4 gene we are
using a new test called the c2n test
that measures plasma
ID and we're using plasma ID as a
biomarker for the first time now to
track interventions so in other words we
are using drugs exercise nutrition Etc
to try to lower plasma ID in high-risk
people talk to me about drugs like this
is one thing statins comes up a couple
times in the book I I the only drug I
take is an anahist amine and I would
stop doing that if I could figure out
what it is either in my diet or my
environment that's giving me the
allergies uh but I've had it across like
seven different places that I've lived
different states I mean it just doesn't
seem to matter um I've had wildly
varying diets doesn't seem to impact it
anyway so I take an allergy medication
um and then I'll sometimes supplement
vitamin D but other than that I I just
have a real hesitation to take any
supplementation whatsoever ever um but
you don't seem to have the same fear I
have of an isolated compound so you get
people on statins if they have early
signs of heart disease not necessarily I
mean when it comes to managing apob
which is the thing we're trying to
manage on the lipid side um we have a
lot of classes of drugs statins are one
class of drug that's one way to lower
apob is to use a Statin Statin also
happen to have the most side effects of
any class of drug that lower lipids in
fact all the other classes of drugs that
lower lipids have no side effects
statins really have the worst side
effects by far so you might say well why
do we even tolerate statins like why
would we even use them we use them
because we have the most data for them
they are very efficacious though not the
most
efficacious um and they may have some
other benefits that go beyond their apob
lowering benefits so all of that has to
kind of be weighed and you have to weigh
that against the downside of statins
which are that a non-trivial subset of
people um have at least one of two
problems in the presence of a Statin one
they get muscle soreness the other
problem is paradoxically their glucose
metabolism Goes to Hell h u not entirely
clear Why by the way but we see
disregulated glucose metabolism in a
small subset of patients on statins and
again we see in a small subset of those
patients about 5% muscle soreness so if
we have those symptoms or signs in a
person on a Statin and we've chosen a
Statin as part of the solution in this
lipid lowering campaign we just
discontinue it and can it reverses like
that but when you prescribe somebody a
drug do you do that only when it's like
they
cannot uh address this via diet and
exercise yeah it depends so um it
depends on several things so certain so
exercise has very little bearing on
lipids it has no clinically meaningful
benefit on lipids has a much better
clinical benefit on metabolic health and
blood pressure which are also very
important in controlling heart disease
so we care a lot about exercise because
we want to control those other things
that drive heart disease the big three
by the way are smoking high blood
pressure and high apob so um we again
we're trying to do all of this in
concurrent fashion as opposed to just
you know playing lacko on one
thing um but nutrition has a
relatively um minor role outside of
extremes at controlling apob um once a
person once you get a person sort of
insulin sensitive uh and once you've
normalized their
triglycerides unless you're willing to
go on profound fat restriction it's very
difficult to get apob in the levels that
we deem appropriate for um true
prevention would you rather put them on
profound fat reduction or generally not
because it usually comes at such a high
cost what's that cost uh usually it they
end up getting insulin resistant because
you're now putting them on a very high
carbohydrate diet and they're usually
protein
malnourished why would that be true so
it just is a function of what they're
eating so for two years so I used to be
60 lbs heavier to lose the 60 lbs I
basically just ate chicken breast and
broccoli and while not fun because I was
also calorically calorically restricted
so hard uh it was fine yeah and if that
works that's that's would that be
preference though over a drug here's
what I say no the answer is no what I
say is diet is a way harder problem to
get right than drug so let's get the
diet right first let's come up with the
diet that works best for your metabolic
Health your muscle mass your um your
sort of fat distribution and your
sanity diet is really hard to get right
M maybe not for you you're kind of a you
know a highly disciplined person but for
most of us we want to make sure that we
can put you on a diet that you're you're
able to stay with for the Long Haul
we're not compromising muscle mass we're
not compromising metabolic health so if
that Diet also happens to produce very
low apob because it's highly restrictive
in fat fantastic stay the course in my
clinical experience taking care of lots
of patients that's not the case for most
people for most people the diet that
produces optimal muscle mass really good
metabolic health and is something that
they can tolerate for a long period of
time it's not sufficiently reduced in
fat enough to have a meaningful impact
on their lipids and therefore if we want
to get apob low enough to really get
into major prevention territory we're
going to need a
drug okay uh uh I'm not sure if it's
more enlightening to find out what stack
of drugs supplements you take or if
based on Horsemen that is likely to kill
you I have people on these but I am
curious what what do you take are you on
rap ay metformin anything like that um I
do take rap ay I do not take
Metformin um I do take uh a lipid
lowering drug I take two lipid lowering
drugs so one of them is called ratha
it's a pcsk9 inhibitor so it's an
injectable drug that um prevents the
degradation of LDL receptors on the
liver so that's specific very specific
so it's a very clean drug has no side
effects uh Works incredibly well it's
the most potent lipid lowering drug we
have did you have a genetic prediliction
to something that made this necessary I
mean I I just only that I have a genetic
pred prediliction to heart disease my
family history is abysmal for heart
disease so um you know once that came
into Focus for me I was very clear that
I was going to do anything and
everything to at least take that off the
table right um and that basically means
not smoking not an issue having low to
normal blood pressure fortunately not an
issue and having physiologic
concentrations of apob meaning lowering
my apob to the level of a child okay and
you
are you able to get to that or is that
what this injectable is for I use these
drugs to do that got it does rap a help
with that no so what's Rapa about
explain what it does to people um well I
I think that's that's a bit of a TBD
right now I mean we we know what it does
in the on-label use so on label use at
rapy which is you know taking kind of a
medium dose every single day is an
immuno is an immunosuppressive dose and
that's how rapamycin was approved in 19
99 by the FDA for use in uh patients
with solid organ transplants so when you
have an organ of somebody else put into
you your immune system naturally wants
to destroy that organ so patients who
get uh organ transplants kidneys or
livers or hearts or things like that
they have to be on a cocktail of drugs
to suppress their immune system
specifically their tea cells which are
the um uh cells that would normally be
going after viruses but now they're
going after the organ so um that's
nothing to really do with how Weir we're
thinking about rapy as we're thinking
about rapy through the lens of what's
called gero protection which means you
don't really have a very specific
disease you're treating you're more
broadly targeting the process of Aging
at the cellular level and there um based
on a lot of animal data that's very
compelling it appears that Romy does
indeed provide jro protection um but
it's very unclear as to how to dose it
to get that um and how you dose it in a
mouse probably isn't how you should dose
it in a human but we don't really know
um so if we don't know why am I doing it
yes yeah I guess I I'm I'm I'm steeped
reasonably well in the literature and I
have a strong enough
conviction that the way we're dosing it
for this purpose has a much higher
probability of being valuable than not
but I'm going to be very quick to abort
in the presence of new information just
as information that you see in the
literature in your blood both all of the
above new studies coming out you know
there's a very important study coming
out in three years um called the Aging
uh the dog aging project I believe it's
called yeah yeah Matt kin y I had him on
the show yeah so so very interesting so
if I remember right from uh talking to
him basically we trying trying to get
out of mtor more or less which is my big
fear with my diet because I'm I eat so
much I mean so much has changed my mind
since reading your book but I eat so
much protein animal protein specifically
I imagine I'm in mtor all the time and
so it was is tempting to try rap a but
is that what's really going on uh not
really I mean well yes Rapa is is an
inhibitor of mtor that's that's how the
drug Works um but it's
not when you eat protein the activation
of mtor is relatively
short so but if you're eating it all the
time wouldn't you then presumably just
constantly be stoking that fire not
necessarily I mean even if you eat like
I do which is no intermittent fasting
there's still 14 hours a day I'm eating
nothing right so um and again amino
acids do not stick around very long in
circulation so you know you're they're
coming on they're stimulating mtor and
then they're gone um if if if mtor if if
um
ramy's benefit is through mtor
inhibition
specifically um it's probably more
through the inhibition of chronic
elevation okay and who knows there may
be tissue specificity it may be more
about what it's doing in one part of you
know in one tissue versus another might
not be in the muscle it might be in the
liver um there there are a lot of
unanswered questions here which is why I
think the work Matt is doing is really
important it's very difficult to imagine
immortality when you untether and
uncouple the uh not dying part with the
preservation of Health span so
specifically cognitive Performance and
Physical performance and I think more
about those things now than I probably
ever have before I think a lot about
sort of the physical stuff so what does
it really mean to be a 100 but function
like a well Todo 50 to 60y old
and and even if you're alive how happy
would you be I mean it would be I think
for many people it would be quite
frustrating or you know if you had
grandkids or great grandkids and you
couldn't play with them or you couldn't
tie your shoe I mean we actually use
tying a shoe as one of the metrics to
evaluate sort of flexibility and and
certain physical performance so most
people our age don't think of tying
their shoe as a physical performance and
yet when you would start to lose those
things I think you'd have a radically
different view of you know what am I
doing but do you get there and and look
perform and feel like the way we imagine
a 60-year-old today a fit 60y old cuz I
know some 60-year-olds that are just
amazing right so how do you how do you
take that to 100 and what would have to
happen for us like what do we really
need to figure out is this
a um flexibility problem joints burning
out problem ATP problem like what what's
the big good question um so far my my
exploration to this topic has has
suggested a couple of things so one is
we do tend to disproportionately load
joints over muscles so in an ideal world
you would want to figure out a way to
exercise where you can maximally load
the muscle while minimally loading the
joint so there is a lot of joint failure
that becomes problematic I mean and I'm
separating the obvious which is there's
just too many people who aren't
exercising enough or correctly at all
and so they're just sort of withering
away but if you come at this through the
lens of okay well what if we're dealing
with a subset of people who are
committed to figuring out how can they
exercise best in many ways it's just a
lack of specificity right so most people
who exercise can't actually tell you why
they're doing what they're doing the
99.9% of us who don't get paid to play a
sport and who aren't even really
competing at a serious level outside of
the professional ranks I don't think we
know what our sport is and I think the
sport should be being the most Kick-Ass
100-year-old that ever lived so what
would that look like like what does it
mean to be the most kickass 100y old and
I think you have to then reverse
engineer all of the things one should be
able to do so a kickass 100 year should
be able to I I don't know I'm making
this up because I haven't fully codified
this yet but they should certainly be
able to carry two 25lb bags from a
grocery store they should be able to
lift a 30 or 40 PB bag over their head
to put it in a you know compartment of
an airport of an airplane they should be
able to have a you know 25 lb little
terror run at the them you know either
great-grandchild dip down into a squat
and grab them and pick them up they
should be able to jump down on the floor
and play with cars or dolls and stand up
without assistance and if you start to
map out the 25 or 35 things that becomes
a new decathlon so instead of saying the
decathlon is running this distance
jumping this far swimming this far it's
like great those are kind of arbitrary
now we're going to come up with like
real world things that you have to be
able to do when you're 100 if you want
to live what I would describe as
potentially uh more fulfilling physical
life to enjoy the fruits of having not
died by that point in your life all
right so how do we build towards that I
love this by the way like I always tell
people I want to live forever I'm well
aware that as of right now I'm going to
die um so my thing is how do we stay
alive long enough to give time for these
step function breakthroughs to happen so
what do I do like what are the things
that I train or the hormone replacement
therapies that I need to go what do I
need to watch what are those things that
I should be doing taking a step back I
would say 3 years ago 80 to 90% of my
energy went into how to not die which
basically strategy yeah which is tan
amount to how do you delay the onset of
chronic disease so the mathematical
equivalent of longevity from a lifespan
perspective is creating a phase shift in
disease onset if you want to live to 100
it basically means you have to delay the
onset by about two decades of every
major chronic disease so it doesn't mean
you can't get cancer or heart disease or
any of these other things but you better
figure out a way to get them 20 years
after the average person gets
them I would say now that occupies 50%
of my brain wave energy whatever and
much more time goes into two other
things which is how to minimize
suffering which is kind of an emotional
problem and then how to be this Kick-Ass
100y old so to the latter
um the model I have in my mind is that
of sort of Bruce Lee Bruce Lee sort of
looked at each and every discipline of
martial arts including boxing and
wrestling and things like that and said
let me extract from each of these
disciplines that which I believe is
useful discard those that I think are
useless and create a perfect fighting
form that is truly geared towards
self-defense so it is not a sport there
is no tournament there is no rank there
is no belt there is no Sensei it is can
you handle yourself in a life or death
situation my wife Lisa struggled
profoundly with her gut health and
experienced debilitating stomach pain so
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or if I do a pilates class invariably
there's something in there that I think
is really valuable and truthfully
there's a bunch of stuff that I'm like I
don't need this this is just if I had
infinite time this would be fine to do
but I don't have infinite time so now
you apply a constraint to the problem
which is not only do you want to be sort
of the best 100y old imaginable what if
you're only willing to spend 10 to 12
hours a week preparing for that
and so you say okay well so there's a
new sport which we Define some of the
parameters of that's your new Olympics
and that Olympics is 50 years from now
how will you train for it if you're only
willing to spend 10 to 12 hours a week
training for it well my guess is you
will take a lot of things from various
disciplines discard a lot of things and
sort of have to build a very bespoke
routine around it that will involve the
maintenance of muscle mass joint
Integrity flexibility uh functional
movement B bance things that we don't
even really think about anymore how many
times does someone who's 90 fall because
they've lost their balance and it's that
fall that ultimately leads to their
demise how much of that the balancing do
you think is neurological and how much
is physical they're just not doing
enough physical [ __ ] to figure out to
maintain that my guess is it's probably
both there's a stability issue that
starts to go away as you age also the
consequences of a fall become much more
apparent so um it's probably not just
the case that someone who's older Falls
that much more it might be that the the
severity of the injury becomes so much
more severe so right now if I were
walking here and I tripped on that stair
and fell you know maybe on a really
really bad day I break my wrist but most
likely nothing happens uh in 50 years if
I do that same thing the probability
that something bad happens is going to
be much greater yeah um but that said I
already can tell my balance is not what
it was when I was 20 MH when I was 15 I
mean I used to do I used to be able to
do this exercise when I was 15 where I
would do a with blindfolded I could do a
single leg squat with the with the non-
squatting leg straight out in front of
me so I could go all the way to the
floor and all the way up arms crossed
blindfolded I could do 20 each leg I
can't do that once today with my eyes
open so admittedly I'm nowhere near as
strong as I used to be so there's a
strength component but I also just
clearly lack the balance and so so the
question is now maybe that activity is a
bit over you know that's just
unnecessary um and again I don't know
what the answer is I don't know if this
means I need to get out there and
practice on a tight RPP or something
like but there's there's something that
needs to be done
so every time I do some sort of really
wellth thought out workout I find myself
thinking God like some percentage of
this is so essential all of those things
need to be put into this new discipline
this new sport which is called for lack
of a better word being a kick-ass
100-year-old I definitely like the sport
now one thing that I found really
interesting is so people complain a lot
about lower back pain talking about
unnecessarily loading the lumbar um I
found that if I don't deadlift my lower
back hurts not if I do deadlift now some
of that probably that I have decent form
it's certainly not exceptional but I
have decent form I know how to avoid
injury um but it is so weird to me that
doing nothing will end up causing me
pain in my lower back but if I'm
religious and I'm doing it you know once
or twice a week every week I feel
Bulletproof the advantage of deadlifting
and squatting to me is uh they reveal
all of your errors in movement right
like they
are I don't know how to describe it but
you can't hide from those movements like
you can't take bad form into those
things and not get revealed right so I
like that the question is is it an
unnecessary risk right am I one bad
deadlift away from doing something
stupid where and and again I you know
I'm as empathetic and in love with those
movements as anybody but I also don't
know if I need to do that to be the best
version of myself as a 100-year-old so
the stuff I've been doing for the last
four to 6
weeks um I basically haven't had more
than 155 lbs on my back in six weeks and
but by changing the form of what I'm
doing and making everything a single leg
movement uh so a lot of curtsy squats
lateral lunges incredibly strict lunges
where you are so specifically loading
the the front leg
glute I got to tell you like I'm not and
then doing a lot of single leg body
weight
squats but with meticulous form so that
I'm fully loading the glute not
overloading the quad which is my
absolute common Mistake by doing these
things I don't feel like I've lost a
step but I absolutely know I'm loading
myself less now the question is does
that matter and I don't think I know the
answer yet so unfortunately I feel like
I'm still too early in this process to
know what the Finish Line looks like and
there's other problems that we haven't
even touched on right like what V2 Max
and what aerobic base are necessary as a
minimum
threshold yeah talk to me about that CU
I hate cardio but it's one of those if I
have to to have the kind of longevity
then so be it and and and the term
cardio is itself so confusing right
because even if you think of what is V2
Max I mean most people think well that's
really a a heart lung issue it's
actually not it's more of a muscle issue
interesting because that's where the the
bottleneck is not in how much oxygen can
you get in your lungs the bottleneck is
how much can your muscles utilize so
when you look at you know the winner of
the tour to France or you know the gold
medalist in you know cross country
skiing or the person who wins the Boston
Marathon like when you when you look at
the most extreme endurance athletes who
have these very high V2 Maxes what's
unique about these people is their
muscles which is counterintuitive
because they're usually very slender
individuals but their muscles are so
efficient at aerobic metabolism that
they are able to extract so much oxygen
out of blood when you and I you know are
at our maximum capacity we're still
breathing out you know 80% of the oxygen
we breathed in so it's really not a gas
exchange problem it's a muscle problem
that said V2 Max is a very specific
energy system that probably gets a
little more credit than it deserves so
what are the Alternatives well um so so
V2 Max is really as its name suggests it
is so the definition is what is your
maximal extraction or utilization of
oxygen the way to experience what that
is is go out and run for 4 minutes as
hard as you possibly can yeah that is
that Energy System but there are other
Energy Systems right there are in
cycling we talk about seven different
Energy Systems but again you can really
simplify this and say there's sort of
the Energy System we're in right now
which is the smoking and joking Energy
System at the far under end of the
spectrum is this neuromuscular area
where you're basically doing the most
explosive movement imaginable for you
know 10 to 15 seconds and I suspect that
for each of those Energy Systems there's
an there's a minimum threshold that
you'd want to be above as you age so
ways that you could test that would be I
mean any even someone our age probably
knows if you carry two bags of groceries
up four flights of stairs most people
are feeling that very few people get to
the top of that fourth I know that
because that's my apartment it's on the
fourth floor so like in New York I'm
always that you know I'm always paying
attention to like what will happen when
when the day comes that this is not
pleasant like when I'm deciding I have
to take the elevator up these four
flights of stairs um
and so if that becomes the minimum
threshold then you and and that you want
to be there at 100 then you need to be
there at 60 and you need to be there at
50 and you need to be there at 40 and so
I think part of it is just defining
those things and that determines then
what's the level of training you need to
do but I do think in this current
environment of everybody loving
high-intensity interval training which I
love just as much as the next person
that's really only training one Energy
System and I
think you if you ignore these other
Energy Systems you're you're sort of not
fully optimizing around your performance
Translating that to this new sport this
100-year-old Kick-Ass sport I think it's
just going to require a little more
thought I'm talking to orthopedic
surgeons and saying okay talk to me
about the injuries that are killing
people um because there's two types of
Orthopedic injuries that kill people
there's fast death and slow death so
fast death is patient falls and you know
within a day or so is dead from whatever
the injury was so they you know break
their femur or they have a fat embolism
they're dead or they fall and they hit
their head and they you know have a
cerebrovascular accident they're
dead um but then there's also the slow
deaths right and these ones are to me
far less talked about but in many ways
more tragic um so so one of my closest
friends his father died recently um 89
years old complications of Alzheimer's
disease he'd been diagnosed eight months
before he died so in some senses you
could say well the good news is he was
spared he and his family were spared a
lot of suffering because you know he's
diagnosed in January he died in
August but when I went home for the
funeral I was sort of struck by how
difficult it had been for him since he
was 81 the two things he loved most in
life which were Golf and tending to his
yard he couldn't do because of more
chronic Orthopedic injuries so he spent
the last decade of his life kind of
watching TV and to me that's the thing
we have to be able to avoid and uh you
know for me I don't know what it's going
to be when I'm 100 but I know that today
if I had to start saying if someone said
well you can't drive a race car and you
can't shoot a bow and arrow and you
can't lift weights doesn't doesn't
matter how heavy it is right but you
can't do these movements or you can't
lay on the floor to play uh if i s if I
had to give those things up I'm not sure
how much I'd want to kick around and so
talking to these orthopedic surgeons is
giving me a real insight into where
those failure are coming from and the
single most important Insight I've
gained from them is something you
alluded to at the outside which is just
joint
overload you know so much of what we do
is even while trying to be good meaning
trying to exercise all these things is
just disproportionately taking on rest
so for I give you one silly example
right a military press is there a time
and a place for a military press
absolutely does it have any role in my
life absolutely not right why not first
of all I don't need to load my spine in
that way and if I could get 80% of the
benefit that I get out of a military
press by doing loaded activities below
my shoulder line below my neck and using
more static loaded Mo movements above
and that gives me 80% of the benefit at
20% of the risk that's exactly the kind
of compromise I'm willing to make and
yet I don't think we're applying that
level of risk reward to how we exercise
cancer I don't know if people are more
afraid of Dementia or cancer but both of
those are pretty terrifying from in
terms of ways to go out uh with cancer
we've I forget how long we've been the
war on cancer we've made precious little
progress are we barking up the wrong
tree like what what is it that either
makes that so hard like if we know what
it is why is it so hard to deal with and
if we don't know what it is why do you
think that's evaded our eye for so
long well it's it's a really good
question um you're right that we have
made scant process in the the most
important metric of cancer which is
overall survival so if you think about
it for everybody who gets cancer we
should be asking the question How likely
is it that they will not die of the
cancer that they just
got um another way to think about that
is How likely are they to be alive in 10
years if you're alive in 10 years after
getting cancer that cancer is unlikely
to be the thing that kills you um and by
that
metric we've only made made about a 5 to
8% Improvement in 50 plus years
wa and that Improvement has been largely
in some very specific cancers so that's
not like across the board we've gotten a
bit better it's like no we got a lot
better in a couple of cancers namely
leukemias and certain
lymphomas couple of other esoteric
cancers like testicular
cancer and aside from that we haven't
really gotten better h uh now very
recently there's some exciting news that
does seem more applicable to a slightly
broader array of cancers which is the a
form of therapy called immunotherapy so
unleashing the immune system to fight
Some solid organ tumors has also proved
to be and some leukemia lymphomas has
proved to be quite promising but we
still haven't figured out a way to
unleash that against every Cancer um
even though in theory it should work
right every Cancer should have at least
some mutations on it that the immune
system could recognize as non-self and
we know for certain that 80% of them do
in fact 80% of cancers solid organ
cancers so these are the ones that are
killing the majority of people right so
breast cancer prostate cancer lung
cancer colon cancer Etc um 80% of those
cancers have what are called novel
neoantigens on them meaning they have
antigens on them that are novel to the
cancer and recognizable by the host's
own immune system the problem is there
aren't enough te- cells to recognize it
to mount a sufficient immune response so
the real challenge of cancer therapy
today in my view is going to be
enhancing that problem that process
rather in other words I think most of
the attention on cancer should be on how
do we create more reactive antigens in
cancer and how we enhance and extend the
longevity of te- cells to attract that
um so I'm I'm actually surprisingly more
optimistic now about this than I was
even when I started writing the book uh
because of what I'm seeing with a class
of drugs called checkpoint Inhibitors
and also for um what I'm seeing with
interesting clinical trials where we're
seeing the pairing of checkpoint
Inhibitors which are immune modulators
and conventional chemotherapy drugs
which take tumors that are not
previously susceptible to this immune
modulation but then create mutations
that then make them
susceptible really clever and cool stuff
I I I think I write about a couple of
examples of that in the um cancer
chapter so
um it's it's easy to be sort of
pessimistic about cancer because of how
poorly it has gone for the past 50 years
but I think the next 10 years look a a
lot better than the last 50 H because of
things that are already in motion yeah
because of these processes that are in
motion so if you got diagnosed with
cancer what would be like step number
one you what kind of cancer is it uh is
it one that responds to immunotherapy is
there like a protocol that you would
walk down no it would be entirely
dependent on what the cancer was but you
know so that gets to kind of step two of
my thinking on cancer which is uh is the
the unequivocal
unambiguous understanding
that your odds for treating cancer go
down the more cancer cells you have in
your body so detecting it sooner in the
book you talk about you for your
patients you lower the age of
colonoscopy we do everything much more
aggressively so we you know we're we're
doing we're doing colonoscopy much
earlier much more frequently we're doing
how often would you do a colonoscopy oh
it depends on the individual I mean in
me I do it every three years really yeah
and then I do stool based testing in
between what do you check in the stool
you're looking for fecal DNA so you're
looking for DNA of colon cancer yeah
interesting how it has its own DNA what
are we looking for yeah you're looking
for the DNA that's shedding from a tumor
tumors have DNA other than it's not my
own DNA it is your own but it's mutated
I mean by definition every I mean cancer
is a genetic disease right so cancer by
definition has mutations that render it
different from the host cell in a way
that's
predictable uh yeah that's we know what
breaks in
DNA yeah we know what's we we're
sampling what's normal because we see
the abundance of that and then we're
looking at what's different from that is
there anything abnormal yeah very that's
what a liquid biop is how would you do
that like the sequencing of that sounds
like a nightmare not anymore I mean you
can sift through that many samples my
God Next Generation sequencing can do
this stuff like it's it's simple how
many sequences would you have to do in a
single feal sample to figure out if
there's one like is it a th000 100 10 um
I think what maybe a better question is
what's the Frequency with of abnormal
cells that can be detected in the
presence of normal and and and that's a
good question I don't know in feal uh I
don't know in the feal test I know in
the blood test it could be one in a
million do you guys speaking of feces uh
do you guys look at the microbiome at
all no really what
don't know what to do with it yet nobody
knows what to do with it anybody who
says they know what to do with it is
probably trying to sell you a
supplement that is probably
true uh okay so I'm startled meaning
look there's no doubt that the
microbiome is an is an important part of
human health like we're not I'm not
sitting here denying that or saying the
Earth is flat there's no doubt that your
diet plays an enormous impact on the
microbiome there's no doubt that you
know a course of antibiotics will alter
like all of these things are true true
but we're still left with the so what
question I've yet to see an example of
where someone can show me that I have a
person in whom I detect a problem I
check their
microbiome I make an intervention in
response to it that I wouldn't have
otherwise made that fixes the problem
wow I just don't see those examples okay
so man this is very interesting and
important to my life so I think we
talked about this before my wife 7 years
ago now I think had a threshold event
where she went from having a manageable
gut issued to I was legitimately afraid
she was going to die her hair was
falling out her nails were breaking she
couldn't keep anything down she was in
agony at times on the floor couldn't be
picked up I was just really really
brutal she had to do things like swallow
cameras colonoscopy endoscopy like I
mean she did [ __ ] everything and this
was long enough ago 7 years that uh uh a
lot of doctors only sort of knew what a
microbiome was like they didn't know
anything about it they only sort of knew
that it existed and so they couldn't
come up with any answers and it was only
through finally getting her tested
realizing she didn't have enough
diversity realizing what we're going to
have to do to start building that
diversity back it was a very long
journey of figuring out what the things
were that she was responding to um
dietary enzymes probiotics prebiotics I
mean just like this whole arsenal now
may just be oh we didn't actually and
and to be honest we don't know which of
those things worked and she's said many
because she takes like 26 supplements a
day or something she's like I don't do I
still need to take them all she's like I
have no idea so she just keeps doing
what she's doing and we don't know the
counterfactual in these situations and
and I guess what I'm what do you mean by
that we don't know what would have
happened if you did something different
yes very true so that this is the
problem with this space is we don't have
clinical trials upon which to extract
knowledgeable or reliable information
why I don't know probably because there
isn't enough financial incentive for the
industries that typically want to do
this right like if you're an unregulated
industry which is the supplement
industry what incentive do you have to
do a clinical trial you don't require it
to sell your product all you need is
marketing so that's why no supplement
company is out there trying to run a
clinical trial clinical trials are only
run by drug companies because they can't
sell their product without a gold
standard of a clinical trial so for as
much as people want to kind of poo poo
drugs and R yayayay supplements they
should really be thinking about this in
the other way the burden of proof is
much higher on a supplement in the sense
that we have no clue if it works let
alone if it's not harmful at least the
FDA for all of its faults and you won't
find many people that are more critical
of the FDA than I am I think it's on the
verge of being a corrupt organization at
least it tries to hold drug companies to
some level of efficacy and safety it
doesn't always do it but at least it's
trying at least they're going through
those motions no one's even trying to do
that with supplements I mean the
supplement industry is such a filthy
disgusting industry that even though I
take supplements I stress more about
sourcing those than I would ever stress
about sourcing Pharma H okay so in other
words you got to be really careful where
you're getting your supplements so if
I'm using a probiotic which I do during
allergy
season interesting a probiotic why you
know I I live in a part of the world
where there are really Wicked allergies
and I don't want to get them so I've
talked to a few allergists and I've said
look what can I do
prophylactically during this season in
Austin where Cedar fever is out of
control and they say well we don't
recommend doing immunotherapy until you
actually develop the allergy blah blah
blah blah blah but a couple of them have
said look we recommend this probiotic we
think it might slightly enhance you know
this element of your immune response and
I'm kind of like okay I if there's a 5%
chance it works and it's not going to
hurt me I'll take the chance because the
only thing I'm doing is wasting money
but like I don't find that to be a very
I mean I do it somewhat reluctantly
right it's so interesting to me that the
microbiome would play a role in
allergies I mean I get it because so
much of the immune system's there but
it's just it's such a unexpected twist
turn of events for me um even just the
discovery that so much my immune system
resides in my gut was already
startling yeah it's it's it I mean again
I think the microbiome is interesting
and I really hope we get to the point
where we know how to manipulate it um
are you do you look at the research on
that or are you waiting for something
more stable to come oh I intermittently
do but but I don't follow that research
nearly as closely as what I'm following
other things so it's it's sort of like
like every year I'll go back and do a
little dive into it with the team and
say okay what is there anything we know
today and you know year upon year upon
year we kind of come back to the same
conclusion which is nothing to nothing
exciting to report yet I mean there are
edge cases right so feal transplantation
obviously very efficacious in some
people um do you worry about fmt um I
mean there are huge risks associated
with it as you know so it's it's it's
it's something that should only be done
when the risks are justified by the
alternative of not doing it yeah we were
maybe a month away from me doing feal
microbial transplant with Lisa cuz I was
just like this is scary yeah
understandable but for reasons of they
just felt like blood transfusions from
like the 70s or something where it's
like are they scanning for the right
things very terrifying so what would you
have done if I had come to you with Lisa
and said hey uh she's always had gut
problems I would have sent you to
someone who who does that like again I'm
not saying that who though like nobody
seems to know like when I say we
finally even I couldn't resolve it for
her as much as I was learning and
meeting with experts like she finally
just had to be like when I eat this what
do I feel when I eat this what do I feel
yeah I mean again this is not my area of
expertise so I wouldn't act like it was
um you know you'd be like I don't know
yeah I'm really happy telling people I
don't know there's a there's there's
more things I don't know than I do know
yeah that is uh that's something that a
lot of people struggle with I definitely
fall into the other camp where I feel
like I know just enough to be like do
this come back report so it was really
interesting reading your book seeing how
much of the things that I felt like uh
in fact I'll say this another way I am
I'm I'm I have a weird emotional hangup
like I really want to I wanted to say
the sentence that I'm going to stop
doing intermittent fasting and and start
doing what you're talking about and I
probably should uh do I have orthorexia
this is a very interesting
question I feel it's so easy for me to
maintain my body composition through
intermittent fasting it's very easy for
me to maintain my uh my satiety through
intermittent fasting it's when I click
over into kosis I find that my
relationship to hunger is different but
you did say that that if I'm doing it
for body composition reasons fair enough
that's very interesting so one thing
that I know I'm just thinking out loud
here one thing that I um I do often
wonder about with my own physique is
protein intake and muscle
hardness when you like when I'm being
really consistent with working out and I
take my carbs up my muscles get really
hard will I have a similar effect by and
you know why that is right uh the
glycogen is being push the muses it's
more water right so more carbs means
more glycogen every molecule of glycogen
is bringing three molecules of water so
you're you're filling up the
muscle okay so then is there none of
that relevance with protein because I
was going to say like it's different
right so so protein is contributing to
the sarir the functional unit of the
muscle the the that's that's that's the
part that's Contracting right that's the
functional piece of the muscle so that's
what's increasing the synthesis of the
muscle and that obviously contributes to
size uh but it contributes just as much
to function um but creatine you know
will add size to muscle through water
retention carbohydrates will add
glycogen and water to muscle these
things are important for performance
also by the way so they're not just an
aesthetic thing so carbohydrates uh
creatine water protein synthesis all of
this matters to
muscle if I were eating more protein
would you expect uh my muscles to feel
more firm what uh am I going to be able
to increase my strength more like it
assuming that I hold my workouts the
same cuz I'm trying I'm trying to think
through do I change my diet or do I just
keep doing what I'm doing now what I'm
doing now is easy but I always thought I
was getting I don't know how you're
working out so I don't know right now
what you're limited by are you limited
by amino acids or are you limited by
Progressive overload or are you limited
by some other Factor so meaning I'm not
overloading the muscle enough yeah are
you over are you putting enough stress
on the muscle or not do you have a high
enough testosterone or not do you have
enough amino acid or not any of those
things can be the bottleneck um and
you're are you're at the limit of your
genes right like all of these things
start to matter now my guess is
virtually nobody is at the limit of
their genes except for bodybuilders so
I'm not at the limit of my genes what am
I at the limit of right now probably and
I'm not at the limit of protein anymore
I'm probably at the limit of how hard
I'm willing to train how much I'm
willing to train and I'm actually I'm
probably at the limit of testosterone as
well because my tea is pretty low so I
can't answer the question for you what
is more protein going to do because I
would need a lot more information to
understand like how you're train what's
your training volume what's your
training intensity and you know all
those factors okay so one thing while I
have you that I I will say is my
limitation when I think about what holds
my physique back I get injured a lot and
I get injured in a very specific
repeatable way which I think has to do
with stability which you cover in the
book so um I have a very weak middle
back and I compensate for everything by
shrugging my traps so it almost doesn't
matter what I'm doing I brushing my
teeth I will suddenly realize Jesus and
I have to like remind myself to I think
it's uh retract my scapular like I I'm
pulling that sort of midback girdle down
um in the book you go into how you can
rewire the way that your brain has
learned to to control your musculature
what what is that process I have injured
my trap you're going to think I'm
exaggerating I've injured my trap 115
times over the 20 years you say injured
your trap say say more sent it into
spasm so where I can't turn my head or I
can't tilt my head uh literally last
night in bed I was rolling over so just
adjusting my posture and it went and I
was like you've got to be [ __ ]
kidding and so then I couldn't fall back
asleep because I could just feel it
tightening and tightening and tightening
and tightening um that is the thing that
has has held me back for forever it's
the first injury I ever received the the
first day in the gym doing an overhead
press it went and I thought I was dying
at that point I was like what the [ __ ]
uh yeah I've injured it probably at
least 115 times again it would be
impossible for me to kind of give you
the diagnostic here but I think I think
if you think about the way I kind of go
through that stability chapter um it
start it starts with respiration so the
first thing we'd have to understand is
what's your respiratory
strategy um so are you over over
inflated underinflated chest breathing
only abdomen breathing only all of these
things um are you chest out are you
hunched over like you'd want to go
through how do you correct your your
respiration strategy um and then you'd
want to look at do you have for example
segmental control of your spine most
people do not I can't imagine yeah so
until you have segmental control of the
spine you are always going to
disproportionately put Force at various
hinge points in the spine do you have
thoracic mobility of your spine sounds
like you don't have thoracic Mobility
the spine do you have SC what is
thoracic Mobility so are you able to
rotate through the thoracic spine so you
have a cervical spine thoracic spine is
the longest segment and then the lumbar
spine um so most people don't have
segmental people that like twist
themselves on a chair that kind of thing
like how would you do that yeah but if
you do twist where are you twisting
through where is the torsion what part
of the spine for me almost certainly
lower back exactly that would be the
most common so most people are
excessively applying torsion in the
lumbar spine and you want to be able to
dissipate it through the whole spine
also when you talk about the flexion
extension of the spine and by the way we
made a bunch of videos like because you
can't explain all this stuff in words so
in the book there's a link to like
videos where I go through what these
things look like um but you know being
able to do a segmental cat Cow exercise
is a really good way to see if you have
segmental control of extension and
flexion of the spine from head to tail
um so you know then we get into sort of
do you have scapular control through the
full range of motion through all four
phases so protraction retraction
elevation depression again very few
people can can control their scapula
through those things so stability and
movement are uh you know intertwined
very intimately and if you you know if
you're trying to unpack these injuries
you generally have to go back to the
breath training how to train yourself
how to breathe properly training
yourself how to move properly and there
are two schools of thought that I have
relied on very heavily in my journey
here and that of my patients and that
one is called Dynamic neuromuscular
stabilization DNS the other is called
postural restoration Institute PRI
bringing everything that I've learned
from this conversation and the book
today tell me if this makes sense so I I
would like to add more MUSC muscle to my
frame do do you know how much muscle
mass you have right now I don't have you
had a dexa scan I haven't man I'm really
like I love that stuff but because no
one's coming to my house to do it uh I
haven't gotten tested it'd be very
interesting you can't do it at your
house you kind of have to go to the
machine I'm I'm willing to do it I would
be very keen to figure that out one I
want to see if I have any well you
should get a Baseline and you should you
know you should figure out like where
you are where do you stack up right now
in terms of muscle mass if for no other
reason then you can evaluate your
progress if you let's say you you know
you test your almi it's at the 70th
percentile that's great but do you want
it to be at the 80th percentile well
this way you can figure out if the
changes you're making are going to move
you in the right direction or not all
right so making my goal maybe even more
broad is something you talk about in the
book which is the centenarian
decathalon uh so what are the things you
want to be able to do when you're older
you better be scoring very high on them
depending on what part of your age
you're in now because it's all going to
decline as you get older so here are the
things I feel like I should be
implementing based on I am 47 okay and
so what do you want to be able to
do 40 to 50 years from now I want to be
able to be very independent from a
Mobility perspective so I love the idea
of being able to um when I'm flying to
Mars to be able to hold I guess before
we Blast Off be able to put luggage
above my head M uh uh so yeah I want to
be able to to travel put things above my
head I don't want to lose a lot of my
strength I want to make and if you want
to go to Mars by the way you're going to
have to tolerate pretty high G forces so
think about the next strength that's
going to be required to do that yes also
I would just like to not have constant
trap injuries that would be amazing y um
I want to be able to play video games
okay tell me I don't play video games I
do drive a simulator though so that's
probably similar uh I would guess not
from the perspective of what I struggle
with so I had so much wrist inflammation
for so long I think a lot about
inflammation inflammation keep that down
so you thank you by the way your uh
encouraging me to add fat to my diet
allowed me to go from basically never
being able to play video games do I can
now play as much as I want on Saturday
which I mean I sure I could play more
than that but that's just from a Time
allocation standpoint so uh that's been
a huge win so being able to do that uh
sex huge thing in my life so being able
to whatever that takes uh so a certain
amount of flexibility I imagine uh
stamina etc etc
um yeah Aesthetics I want to look good I
want to be strong look strong
um something cognitive like being super
sharp that would be really important
well I mean if you're playing video
games presumably you've got to have
pretty decent cognition right you got to
have um certain skills and um depending
on if you want to be doing this yeah
also true I don't need to pick up
grandchildren that would be the maybe
one deviation from what a lot of people
want to be able to do but being able to
be physically active I mean take sex is
my like I want to be able to do that to
the fullest um so given all of those
things here is sort of how I see this
now breaking out um sleep which we
didn't really get into but I obviously
I'm going to need to get sleep that's
going to be super important um I'm going
to need to identify given my family
history I think it's either going to be
cancer or heart disease neither sort of
overwhelmingly prevalent um but those
would be the two where grandparents died
of that so certainly want to be
thoughtful about that so I'd identified
those two Horsemen so I'm going to be
really thoughtful around my diet making
sure that I don't have fat spilling out
uh that I'm really thoughtful about the
um APO little a [ __ ] APO B APO that's
the one that gets into my cell walls
arterial walls yeah and you do need to
check your LP little a which is the
thing we talked about as well that is
genetic and occurs in about 8% to 12% of
people okay so uh paying attention to my
diet uh the adjustment that I'm thinking
about making my diet I'm going to test
not doing intermittent fasting see what
that does for my muscle mass um eating
more protein I have a feeling I might be
lower in protein though I haven't
counted up the eggs I eat a lot of
eggs um and then I'm really curious to
see about cycling Romy
so what is your cycon rap ayon um I just
dose it once a week just take one dose
once a week yep okay very interesting um
trying that what other changes I feel
like that's you're going to have to have
a doctor help you with that that's
that's not an that's not an overthe
counter yeah yeah for sure for sure I
obviously would be doing this on the
back of a lot of blood testing to make
sure that I um am a that I know what my
Baseline is B that I'm actually getting
the result that I wanted
um so yeah looking at the number on the
um the cholesterol that we were talking
about
earlier grip strength is going to be one
again not you know not sitting around
with a little one of those like little
grip squeezers because that's not really
what it's about it's how do you develop
grip strength you develop it by carrying
heavy things right so you know this
morning I was deadlifting and because I
was doing it in the hotel and I didn't
have chalk I was failing in grip today
like it's actually funny my hands and my
forearms are still sore 5 hours later
because I was really at the limits of
what I could do without chalk and you
know I didn't have anything else so so
but so yeah I was deadlifting but think
about how much I was doing for my upper
body even though that's a lower body
activity um you know doing farmer
carries something I love doing I mean
I'm always trying to figure out a way to
use my upper body to maximize the
relationship between grip and shoulder
so think of it less as like very
specific tests that you do um and think
of it more as the the broader activity
you need to do to produce that so grip
strength is just an integral of upper
body
strength all right so if if that is my
sort of fumbly way through the things
the changes that I'm going to make um if
somebody wants to outlive and they come
to you that cocktail party and you just
cannot get away from them
and you have to answer the question in a
succinct way um what do people need to
do to maximize the human life
expectancy there is no sentence I can
give any person to tell them what the
prescription is right I mean if I could
I wouldn't have written a 500 page book
there's no chance believe me I didn't
want to write
a I wasn't look I wasn't looking for
things to do right the reason this is
complicated is that it's complicated um
and
two people can have two very different
prescriptions you know if I'm at that
cocktail party and the person I'm
talking to after a few minutes I figure
out that their biggest issue is that
they're not sleeping you know or that
you know they're sleeping four hours a
night nothing else I'm not going to
really waste time talking about protein
with them we've got to figure out why
they're not sleeping s to n hours a
night and how much of that is sleep
hygiene how much of that is underlying
pathology like sleep apnea or restless
leg syndrome how much of that is alcohol
how much of that like you have to you
have to get to the root of that problem
but if you're sleeping 4 hours a night
that's the elephant in the room if
you're not exercising at all and you're
sleeping well and you're sort of eating
okay like none of that other stuff
matters you need to get exercising if
you have type 2 diabetes and metabolic
syndrome you know I we have to get you
exercising and changing your diet and
all those other things so so again it it
I'm not being difficult because I don't
want to give glib answers I I'm not
giving a glib answer because there isn't
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