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The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
00:27:41
In this quarterly podcast summary (QPS) episode, Peter summarizes his biggest takeaways from the last three months of guest interviews on the podcast. Peter shares key insights from his discussions on diverse topics such as aerobic efficiency and VO2...
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- [00:11]
Peter Attia
Hey everyone. Welcome to a Sneak Peek, Ask Me Anything or AMA episode of the Drive podcast. I'm your host, Peter Attia. At the end of this short episode, I'll explain how you can access the AMA episodes in full, along with a ton of other membership benefits we've created. Or you can learn more now by going to Peteratti md.com subscribe so without further delay, here's today's Sneak peek of the Ask Me Anything episode. Welcome to another special AMA episode of the Drive. Today's episode will be the fourth installment of the Quarterly Podcast Summary. In this conversation, I discuss what I learned from the last quarter of interviews and what I think were some of the most important insights, as well as the things that have resulted in a change in my work and behavior. Please note that I do not think listening to the Quarterly Podcast Summary even remotely constitutes a substitute for listening to the actual episodes. My hope is that it basically helps you think about refining what you might have learned there. And if something you hear in one of these summaries is of interest and you missed the original episode, I hope you'll go back and listen to it. In today's episode, we cover the interviews that I did with Olav Alexander Boo, Ralph DeFronzo, Sam Sutaria, Trena Sutcliffe, and Mike Istratel. And throughout these, we talk on various topics. VO2max power at VO2max insulin resistance, metformin, SGLT2 inhibitors, GLP1 agonists, US healthcare costs, diagnosis and treatment approaches to autism, ADHD and anxiety, Zone 2 resistance training and learning all of the effects of anabolic steroids. And yeah, that sounds like a hodgepodge of topics, but that's because it's pulled from all of these discussions. If you're a subscriber and you want to watch the full video of this podcast, you can find it on our Show Notes page. If you're not a subscriber, you can watch the sneak peek of the video on our YouTube page. So without further delay, I hope you enjoy this special Quarterly Podcast Summary. AMA of the Drive.
- [02:19]
Nick
Peter, thanks for joining us on another AMA on your own podcast. We appreciate you coming by.
- [02:25]
Olav Alexander Boo
I always appreciate being here. Thank you for having me.
- [02:27]
Nick
Anytime, anytime. So today is going to be another Quarterly Podcast Summary episode. A lot of words. Basically what it means is we look at past episodes, cover what the main takeaways are, what your favorite insights were, any changes you made based on behavior to yourself, how you work with patients, how you think about things, anything of that nature from those episodes. The other thing to say is a reminder. It's meant as more to augment the episodes, not necessarily as a replacement. And we get a lot of feedback where people will listen to this and then re listen to some of the original episodes and find a lot of value in it. Today we'll look at Olav talking about training performance, VO2, max, Ralph looking at insulin resistance, type 2 diabetes, metformin, SGLT2 inhibitors, other drugs. So I'm looking at healthcare, trying to understand why healthcare in the US is nearly two times per capita of any other developed nation. Trena looking at autism, adhd, anxiety. We have Mike looking at resistance training and kind of diving into everything revolving that. So huge variety of topics, a lot of different things that I think people should find interest in. And I think we'll get it started with Olav. So do you kind of want to start going through your episode with Olav? This was obviously the second time he was back on a little behind the scenes. We talked beforehand about, hey, let's try and make it a little less technical because the first one was pretty technical and I think looking back, you probably made it more technical than the first. So I think that's just by nature how you and Olav are always going to be. So maybe break down for people what you learned and what your biggest insights were from that. Yeah.
- [04:10]
Olav Alexander Boo
And before we dive into this, at least in as long as we've been doing quarterly podcast summaries, I will say this might end up being the longest because just by the nature of coincidence, and which podcasts fall into the past quarter, this is probably the most voluminous set of notes I've ever taken across a set of podcasts. In fact, I would say that two of the episodes that we've covered here, the one with Ralph and the one with Psalm, were easily 3-4x the volume of notes I normally take. Impute from that what you will. I've done my best to try to synthesize that, but nevertheless, there's a lot going on in this past quarter. Okay, you're right. I wanted to make the Olav one at the outset just straight into less technical things. And I could not resist the tractor pull of trying to at least explain some technical things. So we started the discussion by explaining the difference between things like functional threshold power and critical power. I hesitate to bring these up now because I just don't think they're relevant unless you are a cyclist, but if you are interested, I'll just state it. The functional threshold power, or FTP is the power that you can hold for one hour. That is one way to test it. You literally get on a bike, usually on an erg, so it's a stationary bike and you ride as hard as you can without blowing up for one hour. And whatever the average power is that you held as your FTP, much more typically, for example, when I was a cyclist, we would do this in a 20 minute test and we would discount it by typically 10%, although Olav suggested only 5%. In my experience, 10% was necessary. There's something called critical power, which is very similar, but rather than it being the power you can hold for an hour, it's the power you can hold for 30 to 40 minutes. I think the more important distinction here is that you can calculate critical power much easier. You can do it from a set of curves that are derived from three to four individual tests that are much shorter. Why is this relevant? This is relevant because if you want to have other metrics beyond VO2 max for higher end aerobic efficiency, you might want to know your FTP or critical power. And critical power is much easier to measure. So these days, and this ties into another insight, by the way, these days I don't spend a lot of time worrying about my FTP. In fact, I don't know what it is because I haven't done a 20 minute power test since NOM. Don't necessarily think I'm going to do one anytime soon, probably because I don't want to see how low it is. But it made me realize maybe I ought to do a critical power test just so that I have another benchmark to be tracking. So we talked about a few other things, which I'm not going to go into anaerobic threshold and stuff. We covered a little bit of that in the first podcast. Another very interesting insight that came up for me in this podcast, which was really just a personal insight and I hesitate to spend too much time on it, was talking about the relationship between VO2max and PVO2max or VVO2max. So if you're a cyclist, what does that mean? P VO2max means what is your power when you are at VO2max? Again, VO2max, just to make sure everybody knows what I'm talking about. This is maximum ventilation, meaning maximum oxygen consumption. It's usually sustained for at least a minute when you're doing the test. So what's the highest amount of oxygen in liters per minute that can be consumed for a minute? And this is achieved during a ramp exercise, almost exclusively done on a bike or on a treadmill stationary bike. And when you hit that VO2 max, if you're on a treadmill, you will note that, hey, there's a velocity, assuming you're running flat, or you might see, oh, actually I'm on a bike and my PVO2 max is the power that I've achieved. Now, some have argued that VVO2max or PVO2max are actually more predictive of sports specific performance than just the number VO2 max. And I think there might be something to that because I shared my numbers with Olaf. And the truth of it is I have always had a very low pvo2max to vo2max. Stated another way, I have always had a vo2max that is higher than many people who are much better cyclists than me. It wasn't uncommon when I was training that my VO2 max was 15 points higher than people who had a higher FTP than me, for example. And what Olav suggested there is, it speaks to really inefficient, probably over training aerobically, under training anaerobically. So there's an inefficiency there. And that inefficiency means that I am actually requiring more energy across the board to put out more power. Now something very interesting that comes from that is there might be an association between people like that and a lesser propensity to gain weight. And it is true that every time I've done a resting metabolic expenditure test or anytime I've done the more elaborate stuff, I've actually done the doubly labeled water test in the metabolic chambers, I always seem to have a through the roof energy expenditure for my body weight. So I guess for the first time that all kind of came together which was, wow, on the one hand I have an advantage perhaps in that I have a very high energy expenditure. So relative to somebody else who eats as much as I do, I'm going to be leaner. But the flip side of that is I'm actually quite inefficient at utilizing energy. So again, I found that very, very interesting. One of the things we talked about was, hey, is there anything that a person can do besides the obvious, which is training to boost their VO2 max? He mentioned something about beetroot, wasn't familiar with this, but beetroot concentrate, he said, is rich in nitrates, body converts it into nitric oxide and that of course helps with vasodilation, opens up capillary beds. It should be stated then of course that anything that impairs nitric oxide synthase and there are Many things that do, from homocysteine to insulin resistance, is going to impede it. Again, he said at the elite level this doesn't have much of a difference, but in amateur athletes like the rest of us can be about a 5% boost. The other thing he talked about that I thought was really interesting was, and again, this was to me just more gamesmanship than anything else. And I can't wait to try it the next time I do a VO2 max test, which by the way is probably going to be this weekend or next. He said as you approach failure, do a few breath holds. And he said that that produces a significant boost in VO2 max. Again, it's just a reactive overconsumption of oxygen. I don't know if that means anything. One of the other things that I asked him about was the use of acetaminophen. Again, there are some data that suggests that acetaminophen use can boost peak endurance performance by 1 to 2%. I asked Olaf if Christian or Gustav use acetaminophen themselves during Ironman and he said they did not. And he raised a point that I thought was interesting, which is while acetaminophen or Tylenol can obviously reduce the perception of pain, which has been one of the arguments for why it boosts performance, it may impair the athlete from giving off heat from heat dissipation. And so he just questioned whether or not that might be a worthwhile trade off. Of course, for me, that begs the desire to do an experiment and find out another area that we talked about, which again isn't relevant to me in the way I train. But if any of you are listening and you are really high performance athletes, I think this is arguably probably the single most important takeaway from this podcast is what the upper limits of carbohydrate consumption are while doing cardio activity and racing. So again, if you're a triathlete, if you're a cyclist, if you're a runner, less applicable in running because the races are typically so short. But of course, if you're an ultra marathon runner, that would not be the case. So everybody's kind of done this math, which is if you're doing an Ironman or something like that, you're probably, depending on your level of fitness, expending somewhere between 700 and a thousand calories kilocalories per hour. Let's even be conservative and say you're really, really just going easy. You'd be at 600 to 700 kilo calories per hour. Now, we don't have that much stored glycogen. You've got maybe 50, 100 and maybe 200 grams of glycogen. If you have really big muscles stored, which you're going to run out of pretty quickly, that's going to supply you for maybe an hour and a half. So thereafter, you have to meet your needs from body fat and intake of carbohydrates. And the conventional thinking has always been that you can only consume about 60 grams of glucose per hour. And 60 grams of glucose, of course, is only about 240 kilocalories. This has always been one of my main arguments for why being fat adapted is very important. Because if you're consuming that 60 of glucose and that's giving you whatever it's giving you, you have to get the balance from fat. And you're only going to do that if you're heavily fat adapted. So you get into this cycle. Well, what we've seen unquestionably is, I think the biggest, honestly, the biggest innovation in endurance sports like the Tour de France and Ironman over the past decade is the amount of glucose that these guys are able to consume. He talked about numbers I had never heard before. As some of you may recall, I interviewed today Pogacha recently, the greatest cyclist on the planet. His numbers blew my mind. Of the type of carbohydrate intake that he was tolerating. 150, 180 grams per hour. Olaf said that they're now pushing triathletes at the world class level to 240 grams per hour. Again, this is unbelievable to me. And what that basically tells you is you can meet all of your glycolytic needs indefinitely through that. Now, again, just as today said, you have to train this system, these are athletes that are required to now consume gels and eat carbohydrates at a 12% mixture. What does that mean? 12% mixture means 120 grams per liter, 10% mixture is 100 grams per liter, et cetera. Conventional wisdom is that we can't tolerate, meaning our gastrointestinal system cannot tolerate more than a 5% mixture. And I know for me personally, when I used to be doing ultra distance stuff, I had a hard time going about 5 to 6% myself. But what Olav said, and what Today has also said separately, is you can actually train your GI system to double that. And so how these guys are drinking 2 liters per hour of a 12% mixture, which would be 240 grams, I simply can't fathom. But clearly that's what they're doing. Or they're doing it in some combination. So they're consuming gels plus water that amounts to that mixture. But I think when you look at the hyperbolic performance of endurance athletes today, it's very quick and tempting to just say, ah, they must be just using drugs we haven't figured out yet. Yeah. It's also the fact that I think another explanation, and the one that I find more appealing, is that they literally figured out how to double the octane of the fuel. I mean, that's effectively what's happening. It's like a car that went from racing at 70 octane to 140 octane. And I'm not going to bother explaining what octane is. I'm not even sure if there's a 140, but you know what I'm getting at. So I would say those are probably the most important things. I guess the last thing that I would take away from this is he offered a great protocol for how to make sure you're giving it your best when you do a VO2 max test. This has already been something that I've started implementing a little bit more with our patients and making sure that, for example, if they do a VO2 max test, I've always asked people describe the protocol and many times I'm not pleased with the protocol, but this was the kind of, I think, really super duper protocol. You want to do this at the time of day that is a normal time that you would be training, so you want to be well rested, et cetera, minimize traveling the day before. So we try to tell our patients the same thing. If you're coming into Austin for a VO2 Max test, boy, it would be really great if it was just a short flight the day before. And if it's international, please come in more than a day before if you want to maximize the test. The warmup should be basically six minutes. Very, very easy. Six minutes, zone two, three minutes at threshold or FTP, two to three times at a 10 to 15 second burst at about what you expect. Your PVO2 max is then a relatively short rest of 10 to 15 minutes. Get a drink and then get on with it. Yeah, so I would say that those are probably the most important things, Nick, that I took away from this podcast.
- [16:26]
Nick
So, Peter, just a few follow up questions there. Let's just start with the VO2 max training. So in that protocol, it actually is like a decent warmup that you're having. People do. I remember when I've done VO2 max testing. I don't know if they even really had me do any type of warmup. You just kind of went, hit the treadmill and then started going. So you're having people go through a little bit of a workout before they get going?
- [16:52]
Olav Alexander Boo
Yeah, and I'll tell you this, I do most of my VO2 max testing outdoors now. I use that VO2 master device which I love. I'm going to leave from my house, I'm going to ride 10 to 15 minutes to the place where I do my hill repeat. So that's a warm up in and of itself. And by the way, getting there, there are a couple of short little climbs where I'll do 30 seconds of relatively high power just to get up over a little pitch. I will do two to three full runs of the hill at escalating power before I'm truly going to hit my max. So I'll do like a four to five minute up, maybe 85% of what my maximum power would be for that climb, come down for the same amount of rest period, go up again at maybe 90% of what my maximum power would be, come back down, and then maybe I would go and give it the third one would be out there. So by the time I've done it, I've really warmed up. And so the other day I was talking to a patient who did his VO2 Max test at a facility. It was at a university that he went to do it. It was just like a place where you can go and pay to do it. And I was kind of surprised at what his number was. It was lower than I expected given his training. I said, tell me about the protocol. And he's like, yeah, I just got on the treadmill and they just started cranking it. And I was like, and how long after you started on the treadmill did you hit VO2 max? And he's like, I don't know, five minutes? And I was like, yeah, that's a garbage protocol. You were not warmed up and ready to do that.
- [18:12]
Nick
You mentioned you have a VO2 max coming up. When was the last time you tested prior to this?
- [18:17]
Olav Alexander Boo
In the spring. And the reason is because I like doing it outdoors. I have noticed because I live in Texas, how much of a performance hit I take in the summer. Like, it's a noticeable difference in the summer. So I'm like, yeah, I just would rather do it in the spring. Fall, winter. Spring is when I prefer to test.
- [18:35]
Nick
Let'S say the month leading up to it. So the past month have you changed your training at all? Are you doing anything in particular for it?
- [18:42]
Olav Alexander Boo
Not at all. This is just a data check. It's just like I had my blood drawn this week, had my DEXA scan a couple of weeks ago. I'm doing a VO2 max in general.
- [18:51]
Nick
So if you haven't changed anything, just as a reminder for people, what is your VO2 max training look like in a typical week? Is that one day a week?
- [19:00]
Olav Alexander Boo
Just one day a week? Yeah, it's three days a week of zone two and one day a week of interval training. But interval training at that specific 4, 5 upper limit, 8 minute intervals.
- [19:13]
Nick
And I always like when we talk VO2 max training. I think back to one of the actually first video podcasts we ever did with Alex Hutchinson. Do you kind of want to walk people through? I think a lot of times when you think of VO2 max training or Tabata training or like going all out, a lot of times people kind of lose sight at how hard that actually is. Do you kind of want to walk through if you're doing actual intervals? Real VO2 max training, what that feels like.
- [19:41]
Olav Alexander Boo
VO2 max training hurts less than a true Tabata. I mean a true Tabata. That's where I think people have a hard time understanding what all out means. I mean, technically I don't think the human body is capable of going all out for more than 10 seconds. So even at the level of a Tabata, which is a 20 second effort followed by a 10 second rest repeated eight times or done eight times, even a 20 second, there's just a governor that is self regulating how hard you go. The reverse Tabata, where you go 10 seconds all out, 20 seconds rest for eight rounds, that's about the closest thing that I think we're capable of doing as a truly allout. You will increase your VO2 max doing that type of an exercise, but not nearly, not nearly as much as if you're doing intervals in the three to eight minute range. And by definition, if you're doing something for three to eight minutes, you're not going all out. What you're trying to do is go as hard as you can for that distance and for that time. So it's a different animal. Obviously I think it hurts more because it's a lower level of peak pain, but it's spread out over a longer period of time. So the area under the pain curve is greater, but it's far from all out. And at any moment in time the pain is not the same.
- [20:58]
Nick
Can you remind people, let's say you're doing a four minute interval. You're not starting at four minutes, going as hard as you can and then trying to sustain it. Can you walk through how you think about the energy you put out spread across four minutes?
- [21:12]
Olav Alexander Boo
Yeah. Technically the power is constant throughout the four minutes. So I know in my mind how many watts I want to produce and what I want my average wattage to be over the five minutes. So let's just say I want to do five minutes at 300 watts. Of course you're outdoors so you don't have complete control. It's always jumping around. But I'm really watching the 3 second power tracing and the average power to keep it there. Well, after the first minute I barely know I'm on the bike. It should be really easy after a minute. If you're dying after the first minute, you've set your target too high. Two minutes in, you know, or two and a half minutes in, when I'm halfway done, I still feel pretty good. My heart rate is now going to be within about five beats of what its maximum is, but I still feel pretty good. It's really at about minute three, three and a half that the pain train starts to leave the station and that's when it really starts to feel miserable. And that last minute is really, really difficult. If you've done this right, when you finish this, you're really going to need that four or five minutes of very, very easy pedaling to let your heart rate come back down to then repeat it. But again, the goal is not to have killed yourself in that five minutes such that you can't do it again. Because what I'm trying to do is actually preserve that power across all the intervals.
- [22:32]
Nick
Got it. Last follow up on this is you talked about the consumption and like the increase in performance as a result of what they're able to consume when they're performing. How much of a difference do you think that makes or how can you explain it? A lot of lay people probably aren't thinking about that consumption or their mixture. I know a lot of endurance athletes are, but how much of a game changer do you think it is to have that increase in what they're able to put in their body during events.
- [23:01]
Olav Alexander Boo
Well, again, for people like me and probably most people listening to this podcast, this is not something that should be on our radar. I don't think there's ever going to be a day when I'm doing a 10 hour endurance event again and therefore I don't really need to worry about it. If I'm exercising for two hours, that's kind of a long time. So at two hours I'm fine with just water. I'm living off my own glycogen and whatever. But it's very difficult now to think about people competing at a world class level in cycling and Ironman because what Olav and many others have now argued is the problem of peak endurance is effectively an energetic problem. It's basically a question of how much chemical energy in the form of food can you convert into electrical energy via the metabolism of food back into chemical energy in the form of ATP, back into mechanical energy. Like it's just an energy transfer problem. And more energy input means more energy output. The more logs you can put into the fire, the hotter the fire burns, the more steam it makes, the faster the wheel turns. That's basically what it comes down to. And what we've seen over the past decade is quite literally a more than doubling of the feedstock that goes into the furnace.
- [24:18]
Nick
Got it. All right. Anything else on Olav before we move on?
- [24:22]
Olav Alexander Boo
No?
- [24:22]
Nick
Perfect. So the next is Ralph on insulin resistance, which I think you said was one of the more interesting interviews you've ever done, correct?
- [24:34]
Peter Attia
Thank you for listening to today's Sneak Peek AMA episode of the Drive. If you're interested in hearing the complete version of this ama, you'll want to become a Premium member. It's extremely important to me to provide all of this content without relying on paid ads to do this. Our work is made entirely possible by our members and in return we offer exclusive member only content and benefits above and beyond what is available for free. So if you want to take your knowledge of this space to the next level, it's our goal to ensure members get back much more than the price of the subscription. Premium membership includes several benefits. First, comprehensive podcast show Notes that detail every topic, paper, person and thing that we discuss in each episode. And the word on the street is nobody's Show Notes Rival Hours 2nd Monthly Ask Me Anything or AMA Episodes. These episodes are comprised of detailed responses to subscriber questions typically focused on a single topic, and are designed to offer a great deal of clarity and detail on topics of special interest to our members. You'll also get access to the Show Notes for these episodes, of course. Third, delivery of our Premium newsletter, which is put together by our dedicated team of research analysts. This newsletter covers a wide range of topics related to longevity and provides much more detail than our free weekly newsletter. Fourth, access to our private podcast feed that provides you with access to every episode, including AMAs, sans the spiel you're listening to now and in your regular podcast feed. Fifth the Qualys, an additional member only podcast we put together that serves as a highlight reel featuring the best excerpts from previous episodes of the Drive. This is a great way to catch up on previous episodes without having to go back and listen to each one of them and finally, other benefits that are added along the way. If you want to learn more and access these member only benefits, you can head over to Peterattiamd.com subscribe. You can also find me on YouTube, Instagram and Twitter, all with the handle Peterattiamd. You can also leave us a review on Apple Podcasts or whatever podcast player you use. This podcast is for general informational purposes only and does not constitute the practice of medicine, nursing or other professional healthcare services, including the giving of medical advice. No doctor patient relationship is formed. The use of this information and the materials linked to this podcast is at the user's own risk. The content on this podcast is not intended to be a substitute for professional medical advice, diagnosis or treatment. Users should not disregard or delay in obtaining medical advice from any medical condition they have, and they should seek the assistance of their healthcare professionals for any such conditions. Finally, I take all conflicts of interest very seriously. For all of my disclosures and the companies I invest in or advise, please visit Peter Attia MD.
- [27:32]
Olav Alexander Boo
Where I keep.
- [27:33]
Peter Attia
An up to date and active list of all disclosures.