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

My guest this week is Dr. Peter Attia. I’ve had Peter on the show twice before but it’s been over 5 years since his last appearance. In that period, his work has exploded and today he’s one of the clear leaders on the topic and practice of longevity and health span. He has a new book out called Outlive, which I heartily recommend. You’ll hear us refer to the last chapter of his book early in our conversation but we chose not to reveal the whole story live so you can read and enjoy it. We highlight the big picture in our conversation, including the transition from Medicine 2.0 to Medicine 3.0. I always leave these conversations with Peter full of ideas, and in this case, highly motivated to go outside and move my body in nature. I can think of no better actionable advice. Please enjoy my conversation with Peter Attia. Listen to Founders Podcast Founders Episode 136 - Estee Lauder Founders Episode 288 - Ralph Lauren For the full show notes, transcript, and links to mentioned content, check out the episode page here. ----- This episode is brought to you by Tegus. Tegus is the modern research platform for leading investors. Stretch your research budget with Tegus Expert Calls. Tegus delivers expert calls at a fraction of the cost of legacy vendors, with white-glove custom sourcing for every project at the speed you need to keep your research moving. And we don’t stop there. With rigorous compliance processes baked into everything we do, you can rest assured we’ve vetted every expert to ensure your privacy and protection. Start your next project today with Tegus Expert Calls. As an Invest Like the Best listener, you can trial Tegus for free by visiting tegus.co/patrick. ----- Invest Like the Best is a property of Colossus, LLC. For more episodes of Invest Like the Best, visit joincolossus.com/episodes. Past guests include Tobi Lutke, Kevin Systrom, Mike Krieger, John Collison, Kat Cole, Marc Andreessen, Matthew Ball, Bill Gurley, Anu Hariharan, Ben Thompson, and many more. Stay up to date on all our podcasts by signing up to Colossus Weekly, our quick dive every Sunday highlighting the top business and investing concepts from our podcasts and the best of what we read that week. Sign up here. Follow us on Twitter: @patrick_oshag | @JoinColossus Show Notes Peter on The Tim Ferriss Show Podcast (00:04:15) - (First question) - How Patrick influenced Peter’s decision to launch his podcast (00:05:45) - How Peter has changed in the process of writing this book (00:08:11) - Process of writing the last chapter of this book (00:11:12) - How he stopped dealing with imposter syndrome (00:15:58) - Slow vs. fast death and medicine 2.0 vs. medicine 3.0 (00:22:55) - Doing more early detection screening to avoid slow death (00:27:00) - Impacts of compounding risks (00:31:24) - How do we shift thinking to better lifestyle changes vs. pill popping (00:35:32) - The outsized impact of exercise on health (00:46:18) - Peter’s exercise portfolio (The Comfort Crisis book) (00:50:55) - Why habitual workouts create euphoria for exercise (00:54:45) - How Peter’s views on nutrition have evolved (00:59:30) - Measuring metabolic health (01:01:55) - Where Peter hopes the future of healthcare is heading (01:05:40) - Benefits of mindfulness to health (01:12:55) - Defining your purpose in life (01:16:46) - An index card summation of this book (01:19:45) - Lessons learned being a better interviewer (01:21:46) - Frontier of Peter’s curiosity

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:00Patrick O'Shaughnessy?

  I know firsthand how complex the tech stack is for asset management firms. And seemingly every new tool and data source makes the problem even worse, adding more complexity, more headcount and more risk. RidgeLine offers a better way forward. One unified platform that automates away the complexity across portfolio accounting, reconciliation, reporting, trading, compliance and more, all at scale. RidgeLine is revolutionizing investment management, helping ambitious firms scale faster, operate smarter and stay ahead of the curve. See what RidgeLine can unlock for your firm. Schedule a demo at ridgeline.ai.

• 0:35Patrick O'Shaughnessy?

  Hello and welcome, everyone. I'm Patrick O'Neal and this is Invest Like the Best. This show is an open-ended exploration of markets, ideas, stories and strategies that will help you better invest both your time and your money. Invest Like the Best is part of the Colossus family of podcasts and you can access all our podcasts, including edited transcripts, show notes and other resources to keep learning at joincolossus.com.

• 1:00Speaker 01

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

• 1:32Patrick O'Shaughnessy?

  My guest this week is Dr. Peter Attia. I've had Peter on the show twice before, but it's been more than five years since his last appearance. In that period, his work has exploded and today he's one of the clear leaders on the topic and practice of longevity and health span. He has a new book out called Outlive, which I heartily recommend. You'll hear us refer to the last chapter of his book early in our conversation, but we chose not to reveal the whole story live so you can read and enjoy it. Also, if you want more of the nitty gritty tactical stuff from Peter, I highly recommend his recent podcast episode with Tim Ferriss. In our conversation, we highlight the big picture, including the transition from medicine 2.0 to medicine 3.0. I always leave these conversations with Peter full of ideas and in this case, highly motivated

• 2:17Patrick O'Shaughnessy?

  to go outside and move my body in nature. I can think of no better actionable advice. Please enjoy my conversation with Peter Attia.

• 2:27Patrick O'Shaughnessy?

  Peter, I've been so excited to do this with you. If you can believe it, both of the prior times we've done this were actually in person, which means they were both pre-COVID, which is kind of a gnarly thing to imagine how much time has passed, but it's so nice to see you again. I so enjoyed your book that came out a few weeks ago. I think it's one of these books that will still be read in 10 years and teaching people about health and longevity and how to live. As I thought about framing our conversation, a mantra that my friend Sam Hinky shared with me keeps coming to my mind, and I think it might make for interesting architecture for our discussion. So the mantra is, "Strong body, calm mind, house full of love." And I would love to take that outline with you in discussing all that you've learned. But before we get into Strong Body, I'd love to just understand how you personally have

• 3:12Patrick O'Shaughnessy?

  changed in the process of writing this book. I know it was an ordeal. You restarted it a number of times. You worked incredibly hard on it over a period of years. What did the process of writing the book do to change you most?

• 3:25Speaker 02

  Great question. Before I answer it, though, I do want to give a shout out to you, Patrick, because you are definitely one of probably three people that had the greatest impact on me starting a podcast. So both times that you interviewed me and I sat down with you were not only pre-COVID, they must have been pre-2018.

• 3:45Patrick O'Shaughnessy?

  They were, yeah.

• 3:46Speaker 02

  Yeah, I started that podcast in 2018, almost exactly five years ago. And I remember both times very well that we sat down together and you constantly said, "Peter, you really should be doing a podcast." And I had 100 reasons for not doing it. And I don't know why, on the nth time of your nudging, I said, "Okay, you know what, Patrick, introduce me to the guy, Matthew Patsy, who is your producer and does your podcast, and I'll at least entertain the idea." And of course, you know, here we are five years later, still working with Matthew, thanks to your introduction. So it's actually not clear to me I would be doing a podcast were it not for you. And I can tell you then, from a process perspective, this book would be a fraction of what it is if not for the podcast.

• 4:30Speaker 02

  In other words, the podcast is basically the vehicle that is a forcing function for my learning.

• 4:36Patrick O'Shaughnessy?

  Yeah, amen.

• 4:37Speaker 02

  The book could suck if it weren't for the podcast.

• 4:39Patrick O'Shaughnessy?

  Very cool. That's awesome to hear.

• 4:41Speaker 02

  Okay, so your question was, "How have I changed?" I think greatly. And part of that is just, I think, the natural evolution of change that would have occurred if I wasn't writing a book. But I think what the book does... And what writing does in general, whether it's blogging or doing something as involved as writing a book, is it forces you, at least it forces me, to be a better thinker. And I think that's probably true for most people who write. I never thought of myself as a writer and growing up was more the math-science guy. But when I did start blogging in 2011, I immediately fell in love with it because it became another expression of thought. And I always wanted to think of a better way to explain something.

• 5:25Speaker 02

  And doing it in words requires more precision than doing what we're doing right now. You can tell right now I'm wasting time, wasting words and things. You can't do this when you write. So that's the first thing. It just made me a better thinker and it made me go back and imagine more accurate, articulate, interesting, orthogonal ways to explain difficult concepts and create frameworks. I've always gravitated towards frameworks, but I think it became more important as the complexity of the subject matter evolved. There's a really deep and personal reason or way in which I think I changed through this book, which was, and I kind of allude to this a little bit in the epilogue.

• 6:10Speaker 02

  There was always an uneasiness and a tension I felt in writing this book, which is captured in the last chapter. And then again, I think synthesized through the epilogue, which is there was always a little bit of a feeling of hypocrisy, which was, boy, you're really focused on this living longer thing, but you're really failing in the living better thing, in particular through the happiness, emotional health, connectivity side of things. And I do think that a lot of the fits and starts that I experienced in 2017, 18, 19 were as a result of that internal conflict. And so in some ways...

• 6:54Speaker 02

  Finally getting to the point where I could write the book and finish the book required coming to peace with addressing some of those issues, if that makes sense.

• 7:05Patrick O'Shaughnessy?

  It does. The last chapter of the book is incredibly powerful, and I think those that read it and have read it would agree. It's probably the best chapter, even if it's maybe the most unexpected. What was the process of that resolution? Because it's very easy to say like, I went on a big journey. I learned a lot and I'm coming back with, you know, sort of the classic hero's journey architecture. Like I'm coming back with new truths with the grail, you know, I went to the belly of beast and I got the grail. And here it is. I came back with it. And what people gloss over is what hell that belly of the beast can be. And so what was that process like for you, you backing off that final chapter, coming to that resolution? So powerful.

• 7:44Speaker 02

  Well, depends, right? I think the belly of the beast part was horrible, as you describe it. And it is interesting, right? The hero's journey, it's a bit of a cliche, but it's a cliche for a reason. I think most people who have gone through something that is defining for them will relay some elements of that story. While I'm going through it, of course, I'm not thinking about anything other than the anguish or the shame or the guilt or the pain of it. But it's interesting how when I emerged from it, I finally felt ready to write. And that was something I couldn't have done before. Write about that. Write about that topic. And I didn't feel ashamed anymore.

• 8:27Speaker 02

  And I didn't feel like I was a fraud. This was probably the single biggest thing. We talk a lot about imposter syndrome, and I think a lot of people feel it. If there was an imposter syndrome Olympics, I could have been the Michael Phelps of it. It made me so sick if anybody praised me. It made me so sick if anybody said, great job. It was very weird. I mean, it was weird even having my medical practice where people would come to me thinking that I could help them. And on the one hand, I felt like I could help them. And on the other hand, I had this awful feeling, which I'm sure many people can relate to, which is, oh my God, I hope they don't find out how much I don't know.

• 9:12Speaker 02

  And I was, you know, I don't want to say crippled by or paralyzed by, but perilously close to that for a very long time until I wasn't. And emerging from that is what really allowed me to finish the book. Because if you really think you're a fraud, I don't know how you can write. I don't know how you can produce anything. Certainly something that's nonfiction. Maybe if it's fiction, it's easier to say this isn't really about me. But, but if you're writing something that is supposed to be your best representation of the truth, and you think you're not worthy of writing anything because you don't know anything, that state of conflict is so great, I don't know how you can do it.

• 9:53Speaker 02

  So that might have been the single most important step in getting to that final home stretch in 2020, which is what happened by late 2020, to get to the point where, you know, this book was basically then completed in relatively short order.

• 10:06Patrick O'Shaughnessy?

  I want to ask one more question there because it's almost like alarming to me if I think back on our original conversations and then when I read the book, what you're describing in the final chapter actually happened after our conversations. And if I think back on the, especially the first one, on your point about imposter syndrome, like I would have been one of the people that said like, oh, you want to know about this? This is your guy. This is the, not the Michael Phelps of imposter syndrome, this is the Michael Phelps of longevity research and health span and introducing these concepts into the lexicon. And so it's like very disarming to me that what then happened, as you describe in the book, happens after that. And I would love to understand if you were really feeling those things, what caused

• 10:48Patrick O'Shaughnessy?

  the phase change from feeling like a fraud to not feeling like a fraud, or from imposter syndrome to not imposter syndrome? Like, what was that phase transition? And what precipitated it?

• 11:00Speaker 02

  Well, those are two different things. I think what precipitated... The change is what precipitated the work and what precipitated that was out of my control in the sense that it was kind of hitting at least a local minima, if not an absolute minima. So the stuff I write about in that chapter, which I, you know, I won't give it away in case folks are still going to go ahead and read it, but the personal crises that emerged that effectively left me with very, very hard choices, none of which were good. It just left me with a series of awful choices in my personal life. And fortunately, I chose what was very difficult, but was clearly the best choice, which was

• 11:42Speaker 02

  confronting all of the underlying beliefs and going away. I mean, it meant going, as I write about, going into inpatient residential care for a long period of time on two occasions and doing the hard work that addresses the underlying belief system, which is really the point that you're getting at, which is how do you do that? Boy, I hate to talk about something for which I have so little knowledge, other than my own personal experience. This is one of the challenges of this subject matter is if you're asking me about heart disease and cancer and Alzheimer's disease, I don't have to speak about them from my experience. I can speak about them with expertise, having read the literature in a science where it's not that ambiguous. Some things are, but a lot of it's not. Talking

• 12:26Speaker 02

  about this stuff, it's much more experiential. And I think that we all have a set of beliefs about ourselves. Some of those are healthy, some of those are not. But we tend to, for various reasons, I think, find ourselves at times in places where those beliefs are much more unhealthy than healthy, or more complex, where some of the beliefs produce good outcomes. They produce hard work. The insecurity can produce hard work. The hard work can produce external validation. But on the inside, they're rotting you and the hard work is coming from a bad place, not a good place. So think of this. You can think of two athletes who are performing equally well on the outside. You look at them and

• 13:11Speaker 02

  you think, boy, they're both look great. One of them is doing it from a place of love. Just loves the sport, loves the practice, loves the process, loves the journey. The other one is doing it purely from a standpoint of punishing themselves. We see this a lot in endurance sports, by the way. Just every workout is an opportunity to punish themselves more. They might both end up with the same results. They have a totally different internal milieu. And you wouldn't necessarily appreciate that from the outside.

• 13:44Patrick O'Shaughnessy?

  Yeah, it seems like the unhealthy one of those athletes has this highly revved frenetic internal state, whereas the one doing it from love has sort of the opposite state. Does that describe your own switch, would you say, like from a state of being over revved or hyper revved to one of being calmer?

• 14:02Speaker 02

  Yes, for sure. And I even mentioned that, I think, in the epilogue, which is my quest for longevity was such a frenetic race to avoid death because of my fear of not being here, not my fear of the mechanics of dying, but the real fear of running out of time before I could fix the problem that deep down I knew I had, but wasn't willing to fix. So it was, how do I just buy more time, buy more time, buy more time to fix this thing? I know I need to fix, but I'm never going to fix, but I'm going to kick the can down the road indefinitely. And that's why I'm pursuing this thing.

• 14:47Patrick O'Shaughnessy?

  Holy shit. Such an interesting, beautiful insight. I would love to dive now into some of the incredible findings and discussion and frameworks in the book. And I think to do that, before we get to strong body as a big, important thing to talk about, I was amazed by how much this book was really an ode to working out and being physically active, which is good because we can all do that. I'd love you to describe this framework of slow versus fast death and medicine 2.0 versus medicine 3.0 and how those two frameworks interrelate. I do think they govern a lot of what we'll talk about.

• 15:21Speaker 02

  Before medicine 2.0, obviously, there was something that I'm calling medicine 1.0. And that was basically all of human history until the late 19th century. And we didn't really have a sense of what was going on.

• 15:37Speaker 02

  We didn't understand the natural laws of the universe. We didn't have a scientific method or any of these things that we just take for granted today. And fast death was the norm. So fast death was primarily that of infections, communicable diseases and trauma. That's how people died. That's how we died for millennia. And our life expectancy was relatively short, probably on the order of 30 to 40 years. And look, that was good enough for us to reproduce. And evolution and natural selection did a lot of stuff during that period of time, though they moved at a glacial pace. And again, fast death ruled the land. But somewhere between the late 17th century and the late 19th century,

• 16:22Speaker 02

  over about a 250-year period of time, things began to change. And that sounds like a long period of time, but again, in evolutionary time, that's a relatively short blink of an eye. And basically, you had a new way of thinking, which was these ideas proposed by Francis Bacon around the scientific method and this idea that you could make observations and you could form hypotheses or take guesses about what was causing those observations in nature. And you could design experiments to test those things and compare the results of those experiments to your predictions to then confirm how accurate the prediction was. This was so foreign.

• 17:03Speaker 02

  You could think of this on par with the development of the internet or the development of the airplane or the automobile or electricity. I mean, it was that fundamental an insight. Didn't translate into a tangible thing like an airplane is or like electricity is, where you see the light, but it arguably had at least as much impact. And in fact, you wouldn't have those other things were it not for that insight. Of course, it would be another couple hundred years until another very important technology came along in the form of the microscope that would allow scientists and physicians of that era to actually begin to see things that were previously invisible, namely bacteria and yeast.

• 17:47Speaker 02

  And of course, finally, you had the development of tools to treat these microbes in the form of antibiotics and ultimately vaccines. And therefore, in a span of a really- Evolutionarily speaking, short period of time, we leapfrog from medicine 1.0 to medicine 2.0. And we effectively get rid of fast death. In the span of a couple generations, we double human lifespan by getting rid of infectious diseases. And when I say getting rid of, I just mean reducing their mortality so much so that all of a sudden, an infection doesn't mean the end of your life. Trauma doesn't mean the end of your life necessarily.

• 18:32Speaker 02

  And now we're left with kind of a new problem. And the new problem is, oh, we do live longer now, but we've got a new set of deaths. And these are called slow deaths. And these are the chronic diseases that virtually everybody listening to us talk today is thinking about. Most people today, if they were to imagine what's going to kill them, they're not thinking pneumonia. They're not thinking a staph infection. They're not thinking a urinary tract infection. Those things can still kill you, make no mistake about it. But they're so far down the list now that what dominates death is cardiovascular disease, cerebrovascular disease, cancer, neurodegenerative disease. These are the things that are going to kill people slowly.

• 19:17Speaker 02

  So nobody dies of those things quickly. Even a person who has a sudden heart attack and dies, this disease was taking place for 30 or 40 years prior. So medicine 2.0 was and remains an amazing tool or paradigm for how we deal with fast death. The problem is it has not been very successful at treating slow death. And its strategy has been the way you treat slow death is the way you treat fast death. The way you treat fast death is you intervene when the disease is visible. We don't go around treating people prophylactically for infections. I mean, I guess you could say we do that with vaccines.

• 20:01Speaker 02

  But we don't go around treating people for car accidents before they have them. We wait until they have a car accident, then we treat them. And so when you try to apply that approach to diseases of slow death, it doesn't seem to work that well. We ought to be doing more of the vaccine thing, which is a preventative thing. We're not. Instead, what we're doing is we're saying, look, Once you have diabetes, we're gonna have to do X, Y, and Z. Once you've had a heart attack, or once you have significant risk factors for a heart attack that make it likely that you're gonna have a heart attack in the next 10 years, we really need to get serious about this. Once you have cancer, we're gonna do this operation, we're gonna use this amount of radiation, we're gonna use this type of chemo. And those things have had some effect. I don't want to suggest that they haven't.

• 20:46Speaker 02

  But the effect has been relatively small. So small, in fact, that if you look at life expectancy in the late 19th century and compare it to today, while the nominal change has been a doubling, if you subtract out the causes of death from the top eight infectious and communicable diseases, it's been almost flat. It's a sobering statistic, and it's actually one of the few, this book has maybe 15 or 16 figures in it, that's one of the figures, is just the data that show that analysis. I will tell you, I was very skeptical of those data. I was like, that can't be right. We cannot have been that impotent over the last 150 years. And in reality, it's about a 5% to 10% improvement we've had absent that major change.

• 21:29Speaker 02

  So indeed, it is the case that we aren't really moving the needle much on slow death. And I suspect it's because the name of the game, and this is demonstrated by the centenarians who get a whole chapter in the book, the name of the game is living longer without chronic disease, not living longer with chronic disease.

• 21:50Patrick O'Shaughnessy?

  If you think about the source of that problem, and you could break it down into something like detection and treatment, is it more of a detection problem? Like, it seems like when we identify something, the whole attitude of medicine 2.0 is, if you give me something to work with, we're pretty good at finding solutions. And that these slow death things, we just don't do a lot to screen for things. I'm pretty neurotic about this stuff. I get blood work all the time, and just because of knowing you and your process, like, I know that I'm not getting anywhere near what's available in terms of like early detection for these four horsemen of the slow death. Is that the problem? Like, is medicine 3.0 fundamentally about better early detection of the initial signs

• 22:32Patrick O'Shaughnessy?

  of one of these major ways of eventually killing us and sort of forcing lifestyle changes earlier?

• 22:39Speaker 02

  I think that's part of it. It's also partly a mindset change. And here, I think there is kind of a loose analogy with the transition from medicine 1.0 to 2.0. It required a different mindset. It required different technologies and it required different tools or drugs in the case of antibiotics and vaccines. So similarly here, I think first and foremost, the mindset is key. If you want to transition from 2.0 to 3.0, you have to accept the fact that lifetime risk and treating causal risk factors is the most important philosophical difference. What do I mean by that? Well, the model today for treating cardiovascular disease is, okay, we treat everybody for secondary prevention.

• 23:24Speaker 02

  Secondary prevention means you've already had a heart attack or a stroke. Is there anybody who thinks we shouldn't be aggressively treating those people to prevent the second one, the fatal one? No. Okay, we all agree with that. The real rub comes in what we think about for primary prevention. How do you treat a person who has not yet had a heart attack or stroke? And the mainstream view on that is, well, we use models that predict risk. We have decent actuary models that predict risk based on lipids, smoking history, blood pressure, family history, et cetera. And we wait until there's a threshold that's crossed to begin treating.

• 24:01Speaker 02

  So in the cardiovascular literature, it's typically viewed as about a 5% 10-year risk for a major adverse cardiac event. So if I plug your numbers in, Patrick, and your 10-year risk comes back at 3%, it is not deemed necessary to put any treatment preventive protocols in place. I think that's fundamentally wrong. I've used this example in the book. It's so hard to understand how we feel that way in some cases, whereas we clearly don't feel that in some cases. So one example where we don't act that way is with smoking. So we know that smoking is causally related to lung cancer.

• 24:43Speaker 02

  There's no ambiguity about this, that smokers are 10 times more likely on average to get lung cancer than non-smokers, which of course doesn't mean all smokers get lung cancer and not all lung cancer patients were smokers. 15% of people with lung cancer never smoked and many smokers don't go on to get lung cancer. But nevertheless, that hazard ratio is still 10, which is enormous. Very few things in biology produce a hazard ratio of 10. So we know that smoking is causally related to lung cancer. The implication of that is we tell people not to smoke, period, not to start smoking. And if they do smoke, we tell them to stop immediately, not waiting until their risk of lung

• 25:25Speaker 02

  cancer is high, or waiting until they develop a small lung cancer and then telling them, okay, now it's time to stop. So we clearly have it dialed in in that area. And yet, when it comes to managing diabetes or cardiovascular disease, or other forms of cancer that are not related to smoking, or that have other risk factors, we completely fail in that same line of thinking. We don't treat the causal agents, and we don't take an aggressive enough lifetime risk posture.

• 25:54Patrick O'Shaughnessy?

  Can you say a bit about what I'll call the cross-compounding effect of thinking about all of these things together? So it's not just, I've got the one thing I think about, which is heart disease, because the men in my family died young, or something like this, but rather you're thinking holistically about, okay, we know kind of the major slow death things that hurt us, and the impact of compounding and reducing risks, even if those risks are small?

• 26:18Speaker 02

  Yeah, there are some things where there are really specific risk factors that play into a given disease. And lots of people have done these types of analyses where the suggestion is that, look, even if you eliminated cancer, if you just said, look, imagine nobody will die of cancer, how much does that extend human lifespan? Someone's done that analysis, and they claim the answer is like three or four years. Say, well, that's not that impressive. Okay, well, what about heart disease? If you could just eliminate heart disease and nobody could ever die of heart disease, what's the answer? And it's an equally kind of unimpressive answer. Those analyses are flawed, in my opinion, because what they ignore is exactly what

• 27:00Speaker 02

  you're talking about, which is the interrelationship of these diseases. And so in the book, I talk about these four horsemen of death. And they're loosely the diseases that kill us. But if you read the fine print, you'll realize that we're mostly just dying from three of the horsemen directly. But the fourth horseman is probably the one that has the biggest overall effect, even though it doesn't show up on the death certificate as the cause of death. It's the gasoline that's being poured on the fire of the other three. So the three are. Cardiovascular and cerebrovascular disease at number one, leading cause of death. Cancer, number two, and neurodegenerative disease, number three, at least in a nonsmoking

• 27:43Speaker 02

  population, because I'm stripping out COPD, chronic obstructive pulmonary disease. But the fourth one is kind of a category I've created from a disease such as type 2 diabetes at one end of the spectrum, but also all the things that are leading up to that. So insulin resistance, hyperinsulinemia, non-alcoholic fatty liver disease, which progresses to non-alcoholic steatohepatitis, all the way to type 2 diabetes. Again, if you added up all the death certificates in the country and said, how many times does insulin resistance appear on it? The answer is never. No cause of death is insulin resistance. NAFLD is not a cause of death. You're not going to die from NAFLD, but it progresses to NASH and cirrhosis, you'll die.

• 28:26Speaker 02

  Very few people are dying directly as a consequence of type 2 diabetes. It does show up on the death certificate. I should know those numbers, but they're not that big. But if you have type 2 diabetes, your risk of heart disease, cancer, and Alzheimer's disease is approximately 2X that of someone who does not. So here's where you have to be able to say, I'm not just going to play whack-a-mole with these diseases. The answer is not just do infinite cancer screening and reduce your risk of cancer, or we're just going to treat lipid risk factors and eliminate cardiovascular disease. No, the answer is you have to do all of the above, including addressing metabolic health.

• 29:07Speaker 02

  And this is where the really unsexy, not terribly interesting word that I hate, lifestyle modification, comes in. Because we don't really have amazing drugs to do that, the way we have drugs to zap lipids or treat hypertension, which, by the way, can also be impacted by those metabolic factors. But this is why exercise, nutrition, sleep, stress management, again, they have the reputation for being so uninteresting, because it's like, yeah, yeah, yeah, I know that, I know that, I know that. But it's like, no, A, do you understand how much power those things have? And B, do you understand how to dose them? This is the thing, right? I mean, every doctor knows exercise is important. We are not trained in what that looks like.

• 29:51Speaker 02

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

• 30:04Patrick O'Shaughnessy?

  There's a pill.

• 30:05Speaker 02

  Yeah.

• 30:06Patrick O'Shaughnessy?

  You said mindset earlier, and when I was reading, I didn't think about it in those terms. But now it's very clear that that is central and incredibly important from doctors and researchers all the way down to the mass populace. I want to understand what could cause this mindset shift because strong body and this idea of exercise is just so incredibly powerful as a, if we think about drugs that could affect our longevity, it seems like a lot of exercise of a certain type is probably the single best drug that exists, but it's not the easy top the pill thing that medicine 2.0 mindset has, I guess, trained us as a species to think, oh, if there's a major problem, pop a pill and it gets better. So are you hopeful about this mindset shift?

• 30:52Patrick O'Shaughnessy?

  What can cause this? Because if that's the answer, which is, as you say, kind of unsexy as an answer, but still powerful, then we need to implement it. And it just seems like people are unwilling to work out as much or eat better or sleep better. These aren't the pills people want.

• 31:07Speaker 02

  It's a very good question, and I don't know the answer. So there are a few components that are embedded within that. The first is, is the transition to medicine 3.0, is it necessarily going to have to be driven by healthcare as the system? Or can it be consumer driven or patient driven? So my hypothesis, which I'm happy to be wrong on, is that I actually don't think medicine has to lead the way. I think it can get dragged along the way. In other words, I think enough people can just say, I'm going to take charge of this. I'm going to be in charge of my own healthcare. I'm going to be in charge of my medicine 3.0 approach and my doctor will come along for the ride.

• 31:53Speaker 02

  There are five things that I talk about as the areas that we have agency over in terms of how we impact our health span and lifespan, nutrition, exercise, sleep, pharmacology, including supplements, drugs, et cetera, hormones, and all the tools around emotional health. And this book doesn't really go into much depth on one of those, which is the drug one. And part of the reason for that is that's the purview of medicine 2.0. It would take too long to write a whole dissertation on that. And I wanted to focus on the four other buckets, which are the things that people don't need a doctor for. So if you think about it, if you assume that each of those is responsible for roughly one fifth of the output,

• 32:34Speaker 02

  and it's not, clearly it's not, exercise is actually disproportionately responsible for benefit. So conservatively, 80% of what can impact the length and quality of your life, you don't need a doctor for. It's interesting that 20% of that equation is all we learned in medical school and beyond. So when you encounter a doctor who has insight beyond eat less and exercise more, and there are lots of doctors that do have insights beyond that, you have to understand that those insights came to them through their own education and their own process of learning outside of what they learned in medical school or residency. Because there is nothing we learned in residency that taught us anything about how to provide instruction for patients.

• 33:19Speaker 02

  You know, I use a glib example you may recall in the book, which is knowing that a patient with cancer needs chemotherapy is irrelevant. A person on the street knows that. You don't have to be a medical oncologist to help a woman with metastatic breast cancer by telling her she needs chemo. You need to know what her receptor status is, which chemo? What was the histology of her breast cancer besides even the receptors? How many lymph nodes were positive? How would you dose it? How would you stage it? How would you cycle it? All of these different things, that's where a medical oncologist comes in. Similarly, there's no insight in saying you need to exercise more.

• 33:59Speaker 02

  Or the CDC recommends that you do three hours of vigorous to moderate activity per week. Yes, so what? That's not specific enough. It's not helpful enough. People need, I think, more insight. And I don't think they have to wait for their doctors. To give it to them, look, that's part of why the book is written. It's part of why I have my podcast and stuff, is I want to make sure that people can get the most powerful tools without having to wait for their doctors to provide them that insight.

• 34:26Patrick O'Shaughnessy?

  How do we know that when you consider those five things, that exercise is so disproportionately impactful on the outcome?

• 34:36Speaker 02

  Well, I'll take one of them out because one of them I think can't be quantified. And I think for certain individuals may have a greater impact. And I might be one of those individuals, by the way, which is all the tools around mental health and emotional health. So that could almost be kind of a binary switch where without that one being in order, none of the other stuff matters. It becomes the problem of it doesn't matter how long you're going to live and how healthy you are physically. If your emotional life is in turmoil, who cares? So let's take that one off the table and then just say if we talk about sleep, nutrition, exercise, pharmacology. We don't have and we will never have high enough quality randomized experiments to test head to head all of these interventions.

• 35:21Speaker 02

  So instead, what we can do is we can look at deficiencies in each of these things and ask the question, what are the hazard ratios associated with those things? And we can also do that by combining other problems. And I'll just explain what a hazard ratio is because I've already used that terminology. A hazard ratio is the product of a statistical analysis that I won't get into in great detail because it's actually complicated calculus using something called a Cox proportional hazard where you try to estimate what the risk is of a certain variable or behavior to an outcome.

• 36:03Speaker 02

  So for the purpose of this discussion, I'm going to talk about hazard ratios for all cause mortality. That's the highest standard that we care about in medicine, which is I'm not asking what the hazard ratio is for you getting cancer or even dying from cancer. I'm asking about the hazard ratio of you dying, full stop, period, all causes, cancer, heart disease, you name it. So ACM, all cause mortality hazard ratio is the highest standard. The way a hazard ratio works is it's always reported as a number with a 95% confidence interval. All of the numbers I'm about to spew out have a 95% confidence interval that puts them in the statistically significant category, meaning we are at least 95% confident that these numbers are not by chance.

• 36:47Speaker 02

  A hazard ratio of 1 means that this behavior has no effect on all-cause mortality. A hazard ratio of 1.1 means it is increasing risk by 10%. 1.15 would be 15%, 2.1 would be 110%. You're subtracting 1 from the number and that's your percent. A hazard ratio of .85 would be a 15% reduction. A hazard ratio of .7, a 30% reduction in risk, etc. Okay. So now we go about doing the analyses and we look at enormous populations and we apply statistical corrections and we say, lo and behold, what is known?

• 37:32Speaker 02

  Okay, so we talked about smoking earlier. We know smoking is bad, but how do you quantify how bad it is? Well, one way to do it is to take people who have smoked a certain period of time. Let's just say, we say, let's take all the people who have smoked 20-pack years at least. So they've smoked, say, a pack a day for 20 years or two packs a day for 10 years. And let's compare them to people who are identical as best we can make them statistically, except that they weren't smokers. Now, is that perfect? Absolutely not. Here's why. Anybody who's a smoker versus a non-smoker, there have to be other differences between those people that we can't correct for because a smoker by definition is not going to be as health-conscious. So even though we think we're correcting for what they eat, we know we're not fully connecting for what they eat, exercise, etc.

• 38:18Speaker 02

  So all of these numbers, you have to take, it's almost amazing that we put decimal places on them. We should almost round them. Just round them. Yeah, yeah, yeah. I think we're putting false precision on them. But nevertheless, the hazard ratio for smoking and all-cause mortality is about 1.41. Call it 1.4, meaning directionally, at any point in time, a smoker compared to a non-smoker has a 40% chance greater death rate in the coming year.

• 38:46Speaker 02

  Again, not surprising. I mean, it is amazing, and it is amazing that people still smoke sadly. But yes, because of course, smoking impacts every chronic disease, right? It's enormously increasing your risk of cardiovascular disease, cerebrovascular disease, Alzheimer's disease, and of course, cancer. Okay, let's look at type 2 diabetes. Type 2 diabetes, again, depends on the study. Directionally speaking, it's about 1.3 to 1.4 is the hazard ratio. So roughly a 30 to 40% increase in all-cause mortality. If you look at hypertension, having high blood pressure, it's about 1.2. So about a 20% increase in all-cause mortality. Probably the greatest example of these would be, you know, something like end-stage renal disease.

• 39:32Speaker 02

  So this is a patient whose kidneys don't work anymore, they're now on dialysis. And that comes with a lot of other medical baggage. Of course, that bakes in a lot of other diseases. A lot of times, those patients already have devastating hypertension, type 2 diabetes, et cetera, as the precursor to that. Not always, but often. And that comes with a hazard ratio of about 2.75. That's a 175% increase in all-cause mortality. So let's think about those for a moment. That captures a lot of the nutritional stuff. Like, if you put obesity in there, it's going to be maybe 1.1. About a 10% increase. And that's lower than type 2 diabetes, because of course, obesity per se actually isn't highly associated with mortality if you normalize for metabolic health.

• 40:18Speaker 02

  So obesity is just a very crude, easy-to-measure proxy for bad metabolic health. But technically, only about 70% of people who are obese are metabolically unhealthy. About a third are not. Similarly, about 20% of lean people are metabolically unhealthy, and their risk is much higher. So the real issue is metabolic health. But nevertheless, just to give you a sense of it, obesity and type 2 diabetes, you're seeing, we're talking about somewhere between 1.1, 1.3. So there, you're basically seeing the impact of nutrition. Similar exercises with sleep. People who are sleeping less than sleeping more. Yes, there's unquestionably a higher association with mortality,

• 41:00Speaker 02

  but it's really on the order of 1.1, 1.2, 1.3, 1.4. Not to diminish those things, but when you start to compare those results to the exercise results. And again, don't look at it through the lens of people who exercise versus people who don't. You look at it at the end stage. That's why looking at type 2 diabetes is the integrator of the behavior. So what's the integrator of exercise? Well, the two best ones, three best ones are VO2 max, muscle mass, and strength. Because you can't have a high VO2 max without doing a lot of hard exercise. You can't be in the top decile or quartile for muscle mass and strength without doing some work.

• 41:44Speaker 02

  It doesn't have to be necessarily exercise, by the way. You can just have a very physically demanding job. But the point is, there's no way to hide behind it when you look at these integral functions. And here, the hazard ratios, Patrick, are staggering. When you compare top decile to bottom decile for strength, we're talking about hazard ratios of 3. 200% difference. The biggest gap is when you compare the bottom 25% for VO2 max. Have you ever taken a VO2 max test?

• 42:15Patrick O'Shaughnessy?

  I haven't taken one. I had no other concept, but I haven't taken a test.

• 42:18Speaker 02

  It's a test where you'd either be placed on a treadmill or on a bike. You'd have a mask strapped over your nose and mouth that would be incredibly precisely measuring your oxygen consumption because we know that the air you're breathing in is 21% oxygen. So it's just got an O2 sensor and it's measuring how much oxygen is coming out. So if it's coming out at 17%, it knows 4% was consumed. That is converted into a flow rate. As you're doing this test, it's measuring how much oxygen you're consuming in liters per minute. Now, you and I are sitting here having a discussion right now. Our oxygen consumption rate is incredibly low. It's about 300 milliliters per minute. That's low.

• 43:00Speaker 02

  When you're exercising, the more demand your muscles place on the generation of ATP, the more oxygen you consume, and that number goes up and up and up and up. And by pushing you and forcing you to exercise until the point of failure, we will at some point achieve a maximum level of oxygen utilization. And that's called your VO2 max. And that number is more predictive of how long you live than any other number we have. So if you take people who are your age, your sex, and you compare the bottom 25% to the top 2.5%, the hazard ratio is a little over 5. There's a 400% difference in all-cause mortality. Now, some people are gonna say, "Well, come on, Peter. Who could be in the top 2.5%?" And the short answer is, actually, anybody could.

• 43:45Speaker 02

  It's just a question of how much time you want to train and how long you want to be training. It's a consistency game. You don't have to train 20 hours a week. You can train a fraction of that, but you just never get out of shape. You just constantly work towards improving that. But if you take even something more modest, which say, what if you just take the bottom 25% and compare them, so call that the first quartile, compare it to the third quartile, so people between the 50th and the 75th percentile. Now, that's not a stretch. There's no human being that is not capable of being in the third quartile for their VO2 max. So when you compare bottom quartile, which is basically people who are never doing any exercise, to third quartile, which could be achieved doing five to six hours of exercise

• 44:29Speaker 02

  a week, you're talking about a hazard ratio of 2.75. 175% difference in all-cause mortality. So it's going through these types of analyses, Patrick, that makes it unequivocally clear that exercise is indeed the greatest driver, the greatest lever we have at a longer life. But it comes with a caveat, which is it has to be the right kind of exercise. These generic recommendations of just move, just be active, just garden a little bit, no, that's not gonna cut it. I mean, those things matter, but you won't get the benefits I'm talking about without doing much more specific training geared towards strength and cardio-respiratory fitness.

• 45:13Patrick O'Shaughnessy?

  I love the Nassim Taleb idea of don't tell me what you think, just tell me what's in your portfolio. I'd love to understand your portfolio of exercise. That's one of the things that really stood out to me, reading the book, was the exercise that I'm probably personally most inclined towards, which would be like a six mile trail run or something, not like all out, just probably like a zone three, zone four kind of thing. It's fine, like I get a lot of joy out of it, but it's maybe not the ideal thing to form a great portfolio of exercise. So what has become your portfolio of exercise? Because I think you've got all the data. So you tell me what's in your portfolio.

• 45:46Speaker 02

  Three comments. First of all, I wasn't aware of that statement by Nassim. That's a great statement. Put your money where your mouth is. I don't really care about the pontificating. Just tell me what you're doing. Two, I would disagree with you. And I think that that's a great piece to have in your portfolio. I think that's super important for two reasons. One, it's actually great exercise. That should clearly form a basis of your aerobic training. Secondly, there really is no better way to integrate physical health and emotional health than outdoor exercise. So Michael Easter, who's a good friend of mine and wrote an amazing book called The Comfort Crisis, I'm not sure if you've read that.

• 46:20Patrick O'Shaughnessy?

  Oh, no, I haven't heard of it.

• 46:21Speaker 02

  You should read the book and you should interview Michael. Talks a lot about the benefits of being outdoors from the standpoint of just our natural evolution. So he argues in this book, I've gone back and looked at some of this literature. We'll never know the answer to these because you can't do the experiments. But teleologically, the following makes sense. Did we evolve around symmetry? No chance. We never saw symmetry for a billion years, right? Meaning going back to when we were worms and flies and things like that. We never saw symmetry. Nature is fractal. It is completely asymmetric.

• 47:01Speaker 02

  It's at least plausible that our hyper symmetric, perfectly manicured indoor worlds are at least, if consumed in excess, not necessarily great for our psyche. There is something regenerative about being outdoors. There is something regenerative about being in nature. Even if, again, we can't know that for certain, there are studies that have looked at that by doing functional MRIs. And they all seem to suggest that, but I can also poke holes in those studies. But I think I can't deny the experience that I have when I go outside. And if I'm at the end of a long day, I open my day by exercising and I close my day before dinner by another type of exercise.

• 47:42Speaker 02

  So I'll answer your question in a moment, but rucking has become kind of an obsession of mine where basically I just put on like a 60 pound backpack and I go for a walk before dinner. And A, it's physically strenuous, right? 60 pounds walking around up and down the hills of Austin is pretty strenuous. But I don't take anything with me. This is a very important part of it. There is no phone. I'm not listening to podcasts, audiobooks or music. And it's just it. All I can hear is the breeze blowing and the wind moving the leaves and things like that. And that's a very important 45 minutes to an hour for me. And then I come home, have dinner and get on with the day. Okay. So to answer your question, you're getting that through trail running. You're being out there. You're getting the workout. It's a much better workout than say, if you were running through the city. Okay.

• 48:27Speaker 02

  So my portfolio is purely focused on being the best version of myself physically in the last decade of my life. So everything is geared towards solving that problem, which the model I use for that is called the centenarian decathlon. What are the most important physical events or things, activities of daily living and sports and activities that I want to be able to do in the last decade of my life? So call it 80 to 90. Let's assume, hopefully I can live to 90. So what am I going to be doing between 80 and 90? And then everything has been reverse engineered from what those activities are to what physical skills I need to have. So how strong do I need to be? How much aerobic efficiency do I need to be?

• 49:11Speaker 02

  How high a VO2 max do I need to have? How much balance do I need to have? How much foot reactivity do I need to have? All of these things. And so what I'm doing is about four hours a week of steady state zone two cardio. About 30 minutes a week, up to 60 minutes a week of higher intensity cardio. So pushing that VO2 max system. About six hours a week of strength training that's split mostly equally between upper and lower body. And within that, there's lots of details. What am I doing? And then rucking, probably three to four hours a week of rucking.

• 49:48Patrick O'Shaughnessy?

  When you say it that way, it sounds like a lot, but I want to talk about like the mental side of the physical working out because I think a lot of people think of this as a nasty tasting medicine. They wish there was some spoonful of sugar that helped the medicine go down. But my experience with exercise is that in the period between when you start, when you don't want to do it to when it's habitual, there's this kind of like valley of death where it sucks. On the other side of that valley, it's actually all sugar. Like it becomes the best part of your day, not an obligation. And I'd love to understand why that is. I'm not sure if you experience it the same way, but for me, when I'm in shape, there is nothing that I am more excited for than like a long, hard trail run. Whereas right now, I'm not particularly good shape and the thought of getting going

• 50:33Patrick O'Shaughnessy?

  again is like, ah, damn it. You know, it's going to burn and hurt. My lungs are going to hurt. Everything's going to hurt. But it seems like that's like a misunderstanding that it's like a medicine when in fact, it might actually be like the greatest experience once you get into the habit of it. Are there underlying biology reasons for that experience of almost euphoria associated with exercise?

• 50:51Speaker 02

  Certainly, much has been said and written about endorphins, which are literally chemicals that are produced by muscles. There are many chemicals, by the way, that are produced by muscles. They're called myokines. So yes, there are absolutely neurochemical signals that do make us feel better when we exercise. I try to understand this through the lens of other people. So for whatever reason, exercise has always been something I've loved. So it's harder for me to relate to the people. I know these people, right? I have patients who say, Peter, I hear what you're saying and I know this is important, but I just don't like it. And I'll do it because the data are so compelling. There's no joy in doing this, or I need to find other ways to make this enjoyable, which means I have

• 51:33Speaker 02

  to do it with somebody else. I can't do it without a trainer being there, or I can't do this without having, you know, a movie on while I sit on that bike and suffer. And I guess I would say that's okay. It's better than the alternative. And certainly if you can find ways to bring other things into it, such as being social while you do it, I think that's great. I also think that you're right in that once you get over a certain threshold, the consistency is there.

• 52:00Speaker 02

  I think there's no feeling like it. And there are many days even now when I don't really want to exercise. Usually for me, it has to, it's more of a temporal issue. So if I don't get my workout done first thing in the morning when I normally do, I just develop apprehension about the day and my desire to go in even an hour later is lower. Now, I'll always make myself do it, but it might take half an hour before I'm relaxed and enjoying the workout. So I can at least relate to that component of it, which is, ah, I just have this apprehension. I should be doing something else. The emails are piling up and whatever else is sort of getting in the way. But yes, maybe there's an analogy here to investing.

• 52:39Speaker 02

  If you're talking to kind of a 30 year old who's finally starting to pull in a big enough paycheck that they don't have to live paycheck to paycheck. There is a discipline that comes from saving and it's not easy. But if you get into the habit of doing it automatically and it's no longer a decision. I'm signing up for a 401k plan and that money is coming out of my paycheck before I see it. It hurts a bit less than if you have to make a decision about it every single time you get a paycheck. Or you get your full paycheck and then you have to go in and make some decision to go and invest it or something like that. And I think with exercise, if we just automatically decide we're going to do this thing, it's going to be done early in the day.

• 53:22Speaker 02

  I am an advocate of doing it early. I do find that compliance is much easier if it's done before you start work than after work. And I also think it sets your brain up better for the day. So part of that is just developing a habit around doing something. And then before you know it, it actually becomes pretty automatic.

• 53:41Patrick O'Shaughnessy?

  It's hard to go there, especially when you frame things in terms of hazard ratios. And I just know we're about to collapse. That is a lot. But I asked the question because of our first conversation where we talked a lot about caloric restriction, dietary restriction, time restricted feeding. And just this kind of general concept of nutrition where intuitively it seems like. If I eat nuts and salads and good lean protein, I'm going to feel better than if I eat chicken fingers for every meal. Not much more to be said about it than that, but it seems like your personal views and the data have evolved quite a bit from say, six years ago, when you and I first met and talked about this. Can you say how they've evolved and the degree of importance that you place on nutrition? Let's say with your patients or for yourself relative to six years ago?

• 54:26Speaker 02

  I think nutrition is obviously important and when it's really out of balance, it's

• 54:31Patrick O'Shaughnessy?

  You wreak havoc.

• 54:32Speaker 02

  Yeah, absolutely. Just as the same is true with sleep. So if a person is sleeping four or five hours a night, either through choice or through pathology, that has got to be fixed. You're not going to make tremendous inroads on anything else if their sleep is that bad. But once you get to the point where you're sleeping seven to nine hours per night, which is basically the, oh, I don't know, that's probably the 2.5 to 97.5 arc of the distribution. Once you're in that zone and your staging is reasonable and you're feeling well rested when you wake up, that's it. You don't really need to worry about this problem anymore.

• 55:17Speaker 02

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

• 55:34Patrick O'Shaughnessy?

  I had to stop them for this reason.

• 55:36Speaker 02

  Yes, exactly. And I do, I force patients to take tracker holidays and I sometimes do myself if I just get a little annoyed. So the point is that sleep is an area where you can really get punished if you're outside of optimal, but once you're optimal, there's no super optimal. I think the data would really suggest the same is true for nutrition. If you're really undernourished or overnourished, those things should be corrected. Probably the overnourished is a bigger problem. I mean, it clearly is from a numbers perspective. It might also be health wise, a bigger problem, at least in the developed world. Once you're in that zone of being adequately nourished,

• 56:19Speaker 02

  it's far more important to be focusing on metabolic health and lean mass than to be thinking about the subtle nuances of, well, how much fruit should you eat? Right, right. The reality of it is, I don't think that those things aren't important. I want to be clear. There's many topics I did not write about in this book for the sake of space and time. And certainly, one of the things I'm very interested in is the relationship that soil has on food. This is a rabbit hole I've gone pretty deep down. And I think there's very little doubt that food grown today doesn't have nearly, maybe even half the nutritional value that it could have or should have if the soil it grew in were healthier.

• 57:02Speaker 02

  So there's no doubt that we could be eating better food. But I also think most people tend to over-index that at the expense of exercise. You know, if you look at the absolute battles that people have over social media with respect to this diet versus that diet and what about being vegan? What about being paleo? And it's like, it might not actually matter as much as you guys think. Are you in energy balance? Are you metabolically healthy? Are you getting enough protein? After that, I almost joked that I didn't want to write the two chapters on nutrition because it creates so much substrate for people to argue about things. And what I really want to say is like, those are the three questions that matter most.

• 57:46Speaker 02

  And the rest is just tactics or in strategy around what to do. And of course, I go into all those things. How do you use dietary restriction, time restriction, caloric restriction to address the crisis of overabundance? Which we have. So most people are overnourished. And I don't think there's some magic around how you fix that. The operationalizing of it is hard, but the strategy is really simple. You can calorie restrict, dietary restrict, or time restrict. Each one has advantages. Each one has disadvantages. They're not mutually exclusive, but they are collectively exhaustive. Try the one that works for you. If you fail, go try another one. What I'm trying to get away from is kind of the dogmatic view that there is a right way.

• 58:25Patrick O'Shaughnessy?

  Is there a VO2 max equivalent benchmark for metabolic health? I'm just trying to understand like what metabolic health actually means.

• 58:34Speaker 02

  There isn't a single number the way there is for peak aerobic performance, but there are several things that do matter. So one of them is actually also a functional test. So if you look at a person's zone two capacity, so zone two is, this is a very technical definition, but basically the highest amount of work you can do. So wattage on a bike, for example, while keeping lactate below two millimole. And lactate below two millimole seems to be empirically the place at which you can maintain a steady state where lactate doesn't net begin to accumulate. So at a lactate of two, it seems that you are able to maximally produce and clear simultaneously so that the level doesn't get above two.

• 59:17Speaker 02

  A more practical way to assess that is about the highest level of work you can do while still carrying out a conversation, albeit difficult. So if you can't carry out a conversation, you're out of zone two, you're into zone three. If you can speak, but it's easy, you're in zone one. So zone two, especially the upper end of zone two is, I did a zone two workout today. If my wife and I'm doing it on a stationary bike, if my wife comes in and starts talking to me, I can talk to her, I just don't really want to. If my brother calls me, I'll pick up the phone and we'll talk, but I'll also say, hey, can I call you later? But I can certainly carry on a conversation.

• 1:00:00Speaker 02

  So that's what we call the RPE way about determining it, the rate of perceived exertion. But the more technical ways to do it would be doing it based off lactate levels. You can estimate it based on your heart rate, but truthfully, I think that perceived exertion is the best way to do it for the average person who doesn't want to be checking lactate levels. Well, the more work, the more wattage you can generate at that level, the more metabolically healthy you are. If you look at someone with type two diabetes, they can barely put out one watt per kilogram of body weight before they exceed that threshold. If you look at the best cyclists or runners in the world, they could put out four watts per kilo before they exceed that threshold.

• 1:00:42Speaker 02

  A master's athlete might be two and a half to three watts per kilo. So where you are on there is huge. Then we look at other things like glucose disposal. So using something like an oral glucose tolerance test. What happens when you're challenged with 75 grams of glucose? How much insulin do you require to put it into your muscle? And how high does your glucose get before you put it away? Looking at other markers like triglycerides, which are another marker of fat storage in the liver, looking at transaminases, inflammatory markers. All of these things kind of factor into it. But no, there is not one single number that is the integral of it, the way that we have for peak aerobic performance.

• 1:01:21Patrick O'Shaughnessy?

  What do you hope happens to the industry of health and healthcare in the coming decade or two? Given everything we've talked about today and this hopeful transition to medicine 3.0 to address slow death. You mentioned earlier, being more patient led and dragging the healthcare system along could be a feature, not a bug. But holistically, what do you think the healthiest thing that could happen to the industry itself is?

• 1:01:48Speaker 02

  The challenge with the healthcare industry is that it has three issues that are equally important and intimately linked. And every time you try to solve one, even if you make improvements in it, you tend to make the others worse. So those three issues are quality of care, access of care and cost of care. And if you take stock of where the United States is, we're pretty good on quality of care. In fact, despite all of the things we'll say negatively about the US healthcare system, if you can afford and gain access to the best care

• 1:02:30Speaker 02

  for medicine 2.0 problems, the US system is very good. Now, it doesn't have great care in the medicine 3.0 side, as we've discussed, but it's pretty good on the medicine 2.0 side. But access is pretty bad. Medical costs are the leading cause of personal bankruptcy. And our per capita spend on healthcare is unbelievable. I think we're up to about God, it's gotta be like fourteen or fifteen thousand dollars per capita at this point. I mean, it's absurd.

• 1:02:59Patrick O'Shaughnessy?

  Yeah, crazy percentage GDP.

• 1:03:01Speaker 02

  Yeah, yeah, yeah. It's about eighteen percent of GDP. It's out of control. It'll bankrupt us before anything else does. I'm convinced we will have to address this problem before any other problem for solvency. And then the third one is access to care. So you have both the cost issue, which we just addressed, and then you have how many, what fraction of people are uninsured or underinsured and suffering these problems. So I don't have a solution for that problem. I mean, I wish I could sit here and say, oh, and the solution is we just have to do this, because you don't. There are like ten things that have to be done to address that. Then I think a lot about that problem. That's not what I'm really writing about. I think what I'm really writing about is at the individual level, independent of those problems being fixed, what can you do? Because I certainly, for my health and

• 1:03:45Speaker 02

  the health of my patients, don't want to wait for the system to get better. I don't want to have to wait for medicine as a system to switch to 3.0, or wait for costs to come down, or wait for access to be expanded to everybody, because I do believe that healthcare should be accessible to everyone. I do believe healthcare is a right and not a privilege. And I think that we do require some single payer involvement. I don't think a sole single payer system will not solve our problems. It will solve one problem. It will solve access, might even solve cost, then it will erode quality. Just look at what's happening in Canada and the UK. It's going to have to be a super complicated solution, of which I have lots of thoughts, but again, not thoughts I wrote about because I just felt

• 1:04:30Speaker 02

  it was more impactful to write about it at the level of the individual and what they need to do for themselves.

• 1:04:36Patrick O'Shaughnessy?

  Thinking back to my little mantra, incredible amount of insight around this notion of strong body, both through exercise and nutrition and sleep, and some of those numbers are just staggering. And I think even just for me, I consider myself a very active, healthy person. Like, it's so much motivation to really emphasize exercise and a strong body. What about calm mind? Have you learned through your own experience, through research and the data, through working with patients? When I say calm mind, what does that bring to mind in terms of both importance as an end and also the means to achieve that end?

• 1:05:13Speaker 02

  Well, I mean, I think there's definitely a couple of ways to think about that. So anybody who's ever played around with mindfulness-based meditation, which I have quite a bit, is sobered to realize how noisy the mind is. That type of meditation, for folks who haven't done it, is a meditation where you focus on an object, usually the breath. It's an easy one to focus on. And the whole goal of the meditation is just to be as aware of the breath as possible and to notice every time your mind wanders off the breath onto a thought. And the exercise is making that realization and bringing the mind back to the breath.

• 1:05:55Speaker 02

  So contrary to maybe what people might think who haven't done this meditation, the goal is not to stop thought, because that's not actually possible. It's not possible for more than, in my case, a few seconds. The goal of that exercise, Dan Harris, I think, says this so well. He's like, the muscle, the bicep curl of meditation, is the exercise of noticing that the mind wanders and bringing it back to the breath or the object of meditation. And if that happens 100 times in a 10-minute meditation session, that's not a failure. It's not that you failed 100 times, it's that you got 100 reps in.

• 1:06:33Patrick O'Shaughnessy?

  Nice way of thinking about it.

• 1:06:34Speaker 02

  Yeah, I think that's one of the most compelling arguments I ever heard for meditation, you know, the very first time I heard Dan say that. So what does a calm mind mean? Well, it doesn't mean a mind of no thoughts. Maybe there's some Buddhist monk in Tibet for whom that's the case. For me, it means an awareness of when my mind is hijacking my behaviors. That happens a lot. For me, that's been learning to develop an emotional awareness. So that means recognizing visceral sensations. So for example, yesterday, my wife got upset at me for something and it was actually being able to stop and notice

• 1:07:14Speaker 02

  the physical feeling in my stomach as I was getting angry. So she was getting upset at me and I felt like she was kind of harping on a point that she'd made 10 times. And I sort of felt like, okay, you're right, but you don't need to harp on me for the 10th time. And so the difference is, five years ago, I would have barked right back and I would have escalated. And yesterday, instead, I was able to pause, notice the sensation, understand that I was getting irritated, and simply not react and just say, you know what? How about I apologize again? Yes, I've apologized nine times and I probably don't need to apologize a 10th time.

• 1:07:59Speaker 02

  Like, in other words, it's not my obligation to do so. But harmony matters more to me than being right. And in the end, she is right. Everything she's saying is right. I'm just annoyed by the fact that she's needing to tell me for the 10th time that she's right. So I just said, okay, yeah, you know what? Honey, you're right. I'm really sorry. That was dumb of me to do, and I should have been more clear about X, Y, and Z. To me, that's calm mind. It's almost slow mind, maybe for me, is how I think about it.

• 1:08:27Patrick O'Shaughnessy?

  When I think about calm mind, it very closely relates to the last one, which is house full of love. And another way of saying that is the value of relationship. Maybe the house of your wife and kids being the most important, but not ending there. And that in my experience, as someone that really does is not imbued with a calm mind, but rather with a fairly like hypersensitive, hyper vigilant mind, that by calming it in some weird way, it makes room for more love in the house in an interesting way. And I'd love to hear what you've learned about the importance of house full of love, relationship, where that slots into this big discussion about what it means to live,

• 1:09:09Patrick O'Shaughnessy?

  not just a healthy and a long life, but a good life. And it seems like this final category is the arbiter of that. We don't have a VO2 max for that, or maybe we do. But I've seen you talk about eulogy versus resume virtues before. What an incredible, powerful little term. And I'd love to hear your thoughts on the house full of love and its importance.

• 1:09:31Speaker 02

  Yeah, and of course, I'm taking that from David Brooks, who wrote a great book called The Road to Character, which is one of the books that I stumbled across in the airport during the depths of my despair. And I got very lucky. This was March of 2018. I was really at kind of a rock bottom. I got invited to give a talk overseas, and the talk happened to be on my birthday. And normally, it would be like, well, I can't go because it's my birthday. Like, I'm not going to go and miss my birthday with my family. But at the time, things were so bad at home that it was like a no brainer. It's like, of course, I'm going to go because it's better than the alternative,

• 1:10:13Speaker 02

  which is sitting here alone and not being able to celebrate my birthday with anybody. So I went, and in the airport, I happened to pick up David Brooks's book. I don't know why. I don't know what drew me to it, but sure enough, I just grabbed this book, The Road to Character. And the book talks about the differences between eulogy virtues and resume virtues. And it was just the right thing for me to read at that moment in time. And I realized, boy, and it's an obvious realization, but I don't think I thought about it through this way was, everything I've done to date, and at the time, how old was I? Forty-five, I guess. Every single thing I've done to date has been resume boosting. Nothing has been eulogy boosting. My eulogy is going to be very hollow.

• 1:10:56Speaker 02

  It'll just be the usual platitudes that people say. My kids, if they were old enough, or my wife, would really have much to say about me that is exceptional. They could talk about how smart I was and how hard I worked and all of these things, but I know deep down that that's irrelevant. That was a real turning point. Now, like most turning points, at least turning points of substance, that doesn't immediately result in a change. It's a very slow process, but that's part of the stone mason hitting the stone. And yes, eventually, that stone is going to break, and it will break, of course, as the Jacob Rees quote, is not from that hit, but all the ones that came before.

• 1:11:38Speaker 02

  And that was a very big hit that didn't result in the stone breaking, but was clearly a part of the stone finally breaking a couple of years later.

• 1:11:47Patrick O'Shaughnessy?

  As you think about the evolution of purpose in your life, and it's something I'm just always thinking about and curious about for other people. Can you describe the role of purpose in life and the degree to which you feel like you are operating from a virtuous purpose or clearly defined one? We think about this with companies all the time, like, most people just don't know what they're doing or why they're doing it. They're just doing stuff. And very often, purpose is borrowed. This is like the memetic idea, like, everyone else seems to want this, so I guess I should, so I'll do this stuff to get that thing. How is your own feeling of purpose or definition of purpose evolved over time? And anything you would share with others that might be considering that same question?

• 1:12:32Speaker 02

  Again, it's an area where I just, I feel like I have such little knowledge beyond myself. I hesitate to extrapolate. So I can only say that for myself, sense of purpose is something that is becoming narrower and narrower. And for me, that's a good thing. So for some people, they need a bigger and bigger sense of purpose. I think for me, I have always, from the youngest age, do, I think, to so much of the insecurity and inferiority that I felt, believed I needed to have the greatest sense of purpose and I needed to have the greatest impact and I needed to be doing something spectacular.

• 1:13:17Speaker 02

  With each passing day, I will tell you that my sense of purpose and my focus is becoming narrower and narrower. And I don't care about much outside of my family and my friends in terms of my sense of purpose. My sense of purpose as a father is far greater than any sense of purpose that I have as a doctor, as an author, as a podcaster, as a, you know, an investor. All of the other hats that I wear that do give me purpose and do give me joy and do challenge me and all those things, they don't compare to the thing that matters to me most, which is, are my kids going to be well-adjusted humans?

• 1:13:56Speaker 02

  Are my kids going to have the skills to avoid the pitfalls that I fell into? And what am I doing about that? And also, there's an urgency about this that I don't feel with anything else, which is, we have such a small window of time to be with our kids. You know, I heard on a podcast the other day, and I've seen these data elsewhere. So I think this is

• 1:14:20Patrick O'Shaughnessy?

  This is the Tim Urban thing, how you've spent like all your time with your kids by the time they're eighteen?

• 1:14:23Speaker 02

  That's right. By the time they're eighteen, you're pretty much done. And in my case, it was even less. Once I went to college, I never lived under my parents' roof for another day because even in college, I stayed in the town and got jobs in the math department or things like that. And then boom, went off to medical school in another country, and then I was never back. Been back to Canada a handful of times. So when I think about it through that lens, I'm like, God, nothing else matters. This is the only thing that matters. I'm sure there are some people who could use a little bit more sense of purpose and also need more purpose and fulfillment from their work outside of their family. But for me, I think it's been more about shifting it back to what I truly think matters more.

• 1:15:05Patrick O'Shaughnessy?

  It's amazing to me, hearing you talk at the beginning and now at the end of our conversation about the motivation for large effort and purpose being building evidence to disprove an insecurity. Like, it's such an unhealthy, I think so many successful people, my friend Graham Duncan has this idea of the insecure overachiever and the incredible things that they tend to do. They tend to be able to move mountains. And the effort and the accomplishment looks so impressive from the outside, but the intrinsic motivation maybe is unhealthy. And that you saying having a narrower and narrower purpose, it feels like permission almost to embrace a healthier form of motivation.

• 1:15:46Patrick O'Shaughnessy?

  I find that to be a very lovely idea. If we think about closing down our conversation and everything you've learned in the book, and I forced you to condense it down to an index card that, maybe I'll do this, I'll pay to have it sent everywhere or plane fly overhead and drop them over New York City or something. What would you put on the index card?

• 1:16:08Speaker 02

  What's the font size?

• 1:16:10Patrick O'Shaughnessy?

  Up to you. Legible.

• 1:16:13Speaker 02

  No, it's funny. I was interviewed the other day. I forget it was an outlet, like it was kind of a media outlet and they, they asked me a question that I've been asked so many times and it's typically you're asked on these morning shows and stuff. The question was like, what is the secret to longevity? Like, what's the one thing? The first 10 times I was asked that question, I came up with some sort of nuanced answer. And then the final time I was asked yesterday, I just said, you know what? Honestly, if it could be distilled into one thing, I wouldn't have written a 489-page book. It's not amenable to that. So I won't attempt to do that, right? I won't attempt to synthesize the book into a three-by-five index card. I don't know the answer, Patrick. That's a very hard question because it's going to really depend on who's reading it.

• 1:16:57Patrick O'Shaughnessy?

  My mom used to wear this shirt that said, eat right, exercise, die anyway.

• 1:17:06Patrick O'Shaughnessy?

  Shitty question.

• 1:17:07Speaker 02

  Well, I think it's like, look, maybe you have several versions of those cards and given that this is just a magical thought experiment, when you sprinkle them out of the airplane over New York City, we imagine that each card lands in the hand of the right person. If there's a person who's just not exercising much, that card is just going to talk about, you can literally add 10 years to your life if you adopt this. And oh, by the way, you're going to feel and perform and function so much better, especially at the end of your life, when most people are in so much pain. If it's the person who, we didn't talk about this kind of stuff, but if it's the person who has an elevated LP little a and doesn't know about it, maybe the card simply says, go and get your LP little a checked.

• 1:17:52Speaker 02

  And getting this addressed is going to save 15 years off your life when you don't have that premature heart attack that you don't know is coming because you don't know what LP little a is. And by the way, if it's the person who's outwardly successful or not outwardly successful, but who's entirely miserable and their relationships are all in hell, sort of the person I was, then the card is going to say something about, you've got to stop everything you're doing and get help here and you have to. To be willing to address the demons that got you in this position and nothing else is going to matter until you fix this and it's all, it's all a shell game. You're just numbing your pain with achievement or wealth or whatever else you're pursuing until you get this addressed. So we could probably come up with a dozen of those index cards and

• 1:18:35Speaker 02

  just, I don't know, hope that math gets them in the right place.

• 1:18:39Patrick O'Shaughnessy?

  On the back of my shitty morning show question, you've done a ton of interviewing of your own now. What have you learned about doing that well? As with many things I've seen you do, like it seems as though the rate of improvement has been, we were good to start, but recently I think they're just incredibly dense and interesting and clearly like on the thread of your own curiosity, like you're not filling in a chart of topics, you're pulling a thread of your own curiosity with the world's best people on those topics and the topics, obviously they center around health, but they range widely from there too. What have you learned about the experience of interviewing so many talented people and doing that well? Something I'm always trying to get better at.

• 1:19:21Speaker 02

  Yeah, so am I, Patrick. It's hard. It's really hard and there's a part of me that wishes it was all I did. So when I meet people who, for whom podcasting is their job, I'm quite envious because I think, God, if I had 20 more hours in my week or 30 more hours in my week to put into this, how much better could I get? For example, one thing I don't do, I never go back and listen to my podcasts. So a lot of times in an interview, I'll screw something up, say something and I'll realize that wasn't the right question, but that's nothing compared to what I know I would get if I went back and listened to it as an observer on the outside. So that's an enormous shortcoming. There aren't enough hours in the day because I've opted for something that I think is even more valuable, which is I listen to

• 1:20:06Speaker 02

  other podcasts and I'm listening for podcasts where there's a confluence of two things, my interest in the topic and the quality of the interviewer. There's six or seven podcasters, you being one of them, Patrick, who I really love listening to both the content. The content is interesting to me, but also they're very good interviewers and I learn. Barry Weiss is one of them. Sam Harris is one of them. I could rattle off who all these people are. And I'm a student of this stuff and I just want to get better. And I think I started out as a one out of 10. I would hate to go back and listen to my first year's podcasts. I'm probably a six out of 10 today and we'll never get to be 10. But if we can asymptote at nine, that would be awesome in a couple of years.

• 1:20:51Patrick O'Shaughnessy?

  One of the coolest things about you is you change your mind with the data. You change your mind with experience and through investigation. What is the frontier of your curiosity today?

• 1:21:02Speaker 02

  I think clinically, a lot of it has to do with how can we organize all of the information we have on patients in a risk-based dashboard that allows them to see what we see. So behind the matrix, we internally have such a convoluted, complicated way of organizing risk factors. We see about 40 or 50 inputs into our risk matrix around these seven variables of cardiovascular disease, cancer, neurodegenerative disease, cognitive decline, physical decline, emotional decline, et cetera, orthopedic injury.

• 1:21:45Speaker 02

  But we're still struggling with a really good way to communicate that to patients so that they can see this input tweaks this metric, which then causes us to make this output adjustment. So we can do that in a very crude way. I think it produces good results. It would produce far better results if the patient could see it just the way they could see a dashboard of their car. That's not a very sexy or interesting thing, but at the level of our practice, that's very interesting to me. Another thing that's really on the forefront of what I think about is how to create the

• 1:22:27Speaker 02

  definitive training program for this idea of the centenarian decathlon, this mental model, which I maintain for most people who are no longer specializing in a sport or training for something in particular. If you're really thinking. What does it mean to be an absolute animal of an 80-year-old who can function like a 60-year-old, like a fit 60-year-old? Think about what that means. How do you train for that? And we're doing so much work on that. That just completely obsesses me. So that's the science of movement. That's the science of strength. That's the science of training and fitness and injury prevention and injury treatment and all of those things.

• 1:23:06Patrick O'Shaughnessy?

  Well, Peter, I think it's interesting that as you've described your purpose narrowing subjectively, that with the book and podcasts and other stuff, your impact is probably growing, which is probably a good lesson there. I have learned so much from you over the years, but I do think that Outlive, the book, really distills so much of the incredible amount of hard work and thinking that you and your very talented team have done together. So I'm so thankful for the book. So nice to reconnect in this format. Just a total pleasure. I've learned a lot, like always. Thank you so much for your time.

• 1:23:38Speaker 02

  Patrick, thank you so much for sitting down with me and putting so much thought into this.

• 1:23:43Patrick O'Shaughnessy?

  If you enjoyed this episode, check out joincolossus.com. There you'll find every episode of this podcast, complete with transcripts, show notes, and resources to keep learning. You can also sign up for our newsletter, Colossus Weekly, where we condense episodes to the big ideas, quotations, and more, as well as share the best content we find on the internet every week.