Why Diet Won't Increase Your Lifespan! (Longevity Myths) | Peter Attia Pt 1

Summary

Impact Theory with Tom Bilyeu: "Why Diet Won't Increase Your Lifespan! (Longevity Myths) | Peter Attia Pt 1"

Episode Overview

In this compelling episode of Impact Theory, host Tom Bilyeu sits down with renowned longevity expert Dr. Peter Attia to deconstruct common beliefs about diet, exercise, metabolic health, and the real determinants of human lifespan. Drawing from his new book, Outlive, Attia challenges the idea that diet alone is the secret to living longer, bringing data-driven nuance to the conversation. The discussion delves deep into the mechanisms that govern healthspan versus lifespan, the surprising ways in which obesity and metabolic health can intersect, and the underappreciated power of exercise and muscle mass for longevity.

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Key Discussion Points & Insights

1. The Myth of Diet as the Singular Key to Longevity

• Diet ≠ Cure-All for Lifespan

  • Dr. Attia clarifies that while nutrition is important, it’s not the magic bullet many believe. "Nutrition is an asymmetric input to the equation... it has far more downside if you get it wrong than it has upside if you get it right." (Peter Attia, 03:35)
  • Attia argues that although a poor diet can drastically shorten lifespan, optimizing diet alone won’t extend it dramatically beyond normal human potential.

• Downside vs. Upside Mechanism

  • "Getting it wrong will really hurt you. Getting it right, it's not going to make you live to 200." (Attia, 04:02)
  • The Standard American Diet is referenced as a prime example of how getting diet wrong can cause health crises at the population level.

2. Exercise: The Underrated Game-Changer for Longevity

• Exercise as a "Symmetric" Factor

  • Exercise has both significant upside (when done right) and downside (when neglected). Unlike diet, proper exercise can meaningfully extend both lifespan and healthspan.
  • “Exercise has more of a symmetric upside and downside. If you get exercise right, there's enormous upside… true life extension and health span extension.” (Attia, 04:21)

• VO2 Max & Muscular Strength as Longevity Predictors

  • “There is no number, no biomarker in all of biology more predictive of a person's length of life than VO2 Max.” (Attia, 02:40; reprised at 45:13)
  • Both high cardiorespiratory fitness (VO2 Max) and muscle strength are stronger predictors of longevity than diet or biomarkers like cholesterol alone.
  • "High cardiorespiratory fitness and high muscle mass and strength are more predictive of a long life than anything else we know." (Attia, 33:42)

• Personal Anecdotes

  • Attia recounts his youth as a competitive boxer, eating heavily yet remaining lean and healthy due to extreme physical activity, illustrating how exercise volume can offset poor diet—but only up to a point, and not as we age. (05:45–07:20)

3. Rethinking Obesity, BMI, and Metabolic Health

• Fat but Fit?

  • Up to a third of people classified as obese by BMI are metabolically healthy and have life expectancies similar to lean individuals. (Attia, 21:05)
  • Conversely, lean individuals can be metabolically unhealthy, particularly if they accumulate visceral fat inside organs, which correlates with much higher disease risk.
  • "A lean person can effectively have the blood of somebody who's morbidly obese." (Bilyeu, 20:30)

• Fat Storage Mechanisms: Subcutaneous vs. Visceral

  • Subcutaneous fat (under the skin) is metabolically inert; visceral fat (around organs) is inflammatory and highly damaging.
  • "That 5 pounds of visceral fat is wreaking all the damage... the 45 pounds of fat that is not visceral—totally inert." (Attia, 16:43)
  • Using the analogy of a bathtub: “Subcutaneous fat is the water in the bathtub. The visceral fat is when it gets out and starts leaking through your floors.” (Attia, 16:56)

4. Nuances of Diet, Caloric Restriction, and Protein Intake

• Not All Diets Are Created Equal

  • Three main energy restriction approaches: caloric restriction (counting calories), time restriction (fasting), and dietary restriction (excluding specific food groups).
  • Attia debunks the notion that intermittent fasting has magical benefits separate from calorie reduction, except possibly for muscle mass retention with adequate protein intake.
  • "If you eat 2,000 calories in one sitting, it's no better or worse for you, at least from a weight perspective, than if you eat 2,000 calories spread out over the course of a day." (Attia, 52:58)

• Protein’s Critical Role

  • Recommends at least 1.6 grams of protein per kilogram of body weight, nearly double the RDA—especially important for preserving lean mass with age.
  • "The game is won and lost with protein...most people are being told to eat 0.8 grams per kilogram of body weight and that's literally half what you need to be eating." (Attia, 55:22)
  • Practical tip: To maximize muscle synthesis, protein should be spread across the day in doses of 40–50g, not all at once or in tiny portions.

5. Biomarkers and Personalized Medicine

• Beyond Cholesterol: APOB’s Importance

  • Total cholesterol is largely irrelevant ("as meaningful to dying of heart disease as your eye color"), but the number of lipoproteins carrying cholesterol (APOB) is highly predictive.
  • "APOB...is the concentration of the particles that carry cholesterol into your artery walls— that's what you should care deeply about." (73:26)

• Medicine 3.0: Moving from Treatment to Prevention

  • The new paradigm: extend the period of healthy life (healthspan) through early prevention, not just treat diseases after they begin.
  • "Living longer is not accomplished by living longer with disease. Living longer is accomplished by living longer without disease." (77:56)

6. Notable Case Studies and Memorable Moments

• Sumo Wrestlers and the "Healthy Obese"

  • Attia acknowledges the possibility of extremely large (obese by BMI) individuals who are metabolically healthy due to high physical activity and muscle mass—sumo wrestlers being a hypothetical example. (35:17–37:26)

• Lean Diabetics at Higher Risk

  • "The data absolutely suggests that... it's more dangerous to be a lean diabetic than to be an obese diabetic." (Bilyeu/Attia, 19:40–19:48)

• The Power of Muscle Mass

  • "If you look at people at or above the 75th percentile for appendicular lean mass...their 10-year survival from the age of 72 was 80%. If you looked at people below that, their 10-year survival was 50%." (Attia, 26:13)

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Notable Quotes

• On exercise versus diet:
  "If you are not exercising or you're not exercising sufficiently, there's huge downside. But unlike nutrition...if you get exercise right, there's enormous upside."
  — Peter Attia, 04:21

• On subcutaneous vs. visceral fat:
  "The 5 pounds of visceral fat is wreaking all the damage in their body. The 45 pounds of fat that is not visceral—totally inert."
  — Peter Attia, 16:43

• On muscle’s preventative power:
  "High cardiorespiratory fitness and high muscle mass and strength are more predictive of a long life than anything else we know."
  — Peter Attia, 33:42

• On cholesterol testing:
  "APOB... is the concentration of the particles that carry cholesterol into your artery walls—that’s what you should care deeply about."
  — Peter Attia, 73:26

• On healthspan vs. lifespan:
  "Living longer is accomplished by living longer without disease."
  — Peter Attia, 77:56

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Important Segment Timestamps

• 02:40 — The single most predictive metric for lifespan: VO2 Max.
• 03:35–04:21 — Asymmetry of diet’s role: importance of not getting diet wrong.
• 05:08–07:20 — Personal anecdotes about youthful over-eating and extreme exercise.
• 13:56–16:43 — Discussion of how and where body fat causes damage.
• 19:40–20:22 — Why lean diabetics are at higher risk than obese but metabolically healthy individuals.
• 21:05–21:33 — The proportion of metabolically healthy obese people.
• 33:42–34:09 — Strength and cardiorespiratory fitness as cornerstones of longevity.
• 45:13–47:15 — What is VO2 Max and how is it measured.
• 52:58–55:21 — Debunking intermittent fasting and setting protein requirements.
• 73:26–76:53 — APOB as the critical cholesterol biomarker.
• 77:31–80:20 — Defining Medicine 2.0 vs. 3.0 and the future of prevention.

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Takeaways for Listeners

• Diet modification is crucial to avoid disease but cannot alone grant extraordinary longevity; exercise is essential for significant lifespan and healthspan gains.
• Both muscle strength and VO2 Max are actionable, measurable targets anyone can strive for to meaningfully improve their odds of a long, healthy life.
• Assess metabolic health with markers like visceral fat and APOB rather than just BMI or total cholesterol.
• Protein intake should be higher than commonly recommended, and properly spaced throughout the day to maintain muscle.
• Prevention and holistic health management (exercise, diet, sleep, emotional health) define the new frontier in medicine and longevity science.

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For more, delve into Part 2 of this conversation, or grab Peter Attia's book, Outlive, for a deep-dive into the research and practical guidance behind these powerful ideas.

Transcript

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[Tom Bilyeu]

What's up everybody? Longevity is an obsession of mine. It's a topic I've been focused on for years and it's something I'm always excited to talk about. And my guest today, Peter Attia, is one of my favorite people on this topic. I think he's insanely knowledgeable. He's the co founder and Chief Medical Officer of the popular fasting app Zero as well as a best selling author, podcast host and longevity expert. In the first part of this two part episode, Peter continues the trend recently of upending ideas around health, longevity and body fat that I thought I was so sure about before reading his latest book, Outlive. I loved recording this episode and in it Peter breaks down why diet isn't the cure all that we thought it was. And he explains the difference between lifespan and health span, which is very important to understand. And we get right into how it actually is possible to be obese and still be metabolically healthy. I cannot believe this is true. As a side note, we've just launched our exclusive Impact Theory subscription service that takes your podcast listening experience to the next level. So if you are tired of ads cutting into your favorite episodes and the best part, we've got you covered with our extra Impact subscription. You can listen to Impact Theory completely ad free. But that's not all. We've also curated amazing playlists on topics like health, mindset, business and relationships, making it easy for you to deep dive with hundreds of experts and relevant relevant topics. Plus, we're offering bonus monthly episodes that you won't find anywhere else. Click through the Show Notes to subscribe to Apple Podcasts or Supercast and guys, do not wait on this. The time to invest in yourself and access this incredible resource is right now. Get ready to unlock your true potential and enjoy an unparalleled listening experience with our Impact Theory subscription service. Plus, it's the best way to support the podcast so that we can get to more people just like you and help them be legendary. I'm Tom Bilyeu and welcome to Impact Theory.

[Peter Attia]

The higher that level, the longer you're going to live. There is no number, there is no biomarker. There's no finding in all of biology that is more predictive of a person's length of life than that specific number.

[Tom Bilyeu]

You have a quote in the book that goes something like, I used to think that diet and nutrition were the cure alls, and now I'm not so sure. How is it possible that diet and nutrition, which would have been the thing. And I've said many times on this show, if you just let me control 100% what people eat, I've got them covered. I'll control their body composition. But the one thing I always caveated was, I don't know that I'll keep them alive longer because I'm running an N of one experiment. So what made you start to lose faith that diet and nutrition were the answer?

[Peter Attia]

Well, I think it's important to differentiate between a couple of things. So I definitely don't want what I've written or what you've correctly interpreted to imply to people that I don't think nutrition is important. Right. What I'm really saying is nutrition is an asymmetric input to the equation, if we want to think about it technically. Meaning it has far more downside if you get it wrong than it has upside if you get it right.

[Tom Bilyeu]

That's interesting.

[Peter Attia]

Does that make sense?

[Tom Bilyeu]

Yeah. So getting it wrong will really hurt you. Getting it right, it's not going to make you live to 200.

[Peter Attia]

That's right. I mean, first of all, I don't think anything will, but yes, that's the right idea. No, absolutely not. So. So if you get it wrong, and let's be clear, we are living in a case study of getting it wrong. Right.

[Tom Bilyeu]

Most of us, meaning the standard American,

[Peter Attia]

the standard American diet, is all about getting it wrong for virtually everybody. So we're, we're watching proof positive what it means to get it wrong. But what I want people to understand is it's very easy to get to that point where you think, okay, I'm going to fixate on this thing and it's going to get better. And that's wonderful, by the way, if you do. But you're, if you do that at the exclusion of some of the other things, namely exercise, you're really leaving an opportunity on the table. And exercise has more of a symmetric upside and downside. In other words, if you are not exercising or you're not exercising sufficiently, there's huge downside. But unlike nutrition, if you get exercise right, there's enormous upside. There is true life extension and remarkable health span extension, which might be even more important.

[Tom Bilyeu]

I'm really, I'm bothered by that. And it uplifts.

[Peter Attia]

Why are you bothered by that?

[Tom Bilyeu]

Because I hate exercise, dude, in a way that you can't imagine. So literally, while I was reading your book, which I always do as an audio format, I was doing air squats and sit ups and stuff, because just hearing you talk about the importance of exercise, it really is the thing that I have always done out of obligation and never out of joy. So I always thought, again, literally until reading your book, that I was way better off controlling diet. And you get this, the classic phrase, you can't outrun a bad diet, can you? Like, are you saying that you can?

[Peter Attia]

Well, again, we want to. So that's a complicated answer, which we'll take in steps. So there's probably a season in your life when you can, generally when you're young, and if that exercise is at a high enough level, you can. So just using my own personal example. Absolutely. When I was growing up, so in my teenage years, right, 13 to 19, I didn't pay any attention to what I ate other than I was always eating. And when I say I was always eating, I'm not exaggerating, Right. Like I. Every morning breakfast was a box of Fruit Loops or Captain Crunch or some unbelievable crap that could only be consumed in a Tupperware bowl bigger than my head, you know, with a liter of milk. Lunch was usually seven sandwiches, which was only a full loaf of bread. What were you doing? I was exercising six hours a day.

[Tom Bilyeu]

Jesus. Were you a wrestler or something?

[Peter Attia]

Boxer.

[Tom Bilyeu]

Oh, yes.

[Peter Attia]

So you know, running minimum five, typically closer to 10 miles every morning, 25 minutes of rope jump, two and a half hours of weight training, sparring bag work every single day, 400 pushups before bed every single night. With one exception. One night in high school. I didn't make it happen.

[Tom Bilyeu]

Wow. You actually remember that. It was only one time, one night

[Peter Attia]

I was so goddamn sick that I couldn't get out of bed for a whole day. And that was the only night in all of high school I didn't do my 400 pushups before bed. And I was so pissed off that

[Tom Bilyeu]

even now you remember that there was one day. I love it.

[Peter Attia]

But my point is, I didn't stop eating. I was eating french fries crap all day, every day. I couldn't gain weight. I was trying to move up a weight class.

[Tom Bilyeu]

I couldn't because of the exercise or your genetic proclaimer?

[Peter Attia]

No, I just think, I mean, that much exercise, you can eat whatever you want. Now, could I exercise that much today? Could I out exercise a bad diet today? No. At 50 I can't do what I could do when I was 15.

[Tom Bilyeu]

Right. I want to get into the mechanisms of that. So here's another one of my ignorant statements that I live by. This is all a game of controlling your glucose. And that if you let me control your glucose levels, then I basically control your destiny. And I want everybody listening to know that after reading this book, I know this is probably not only overly simplistic, but maybe even just wrong.

[Peter Attia]

Correct.

[Tom Bilyeu]

But in exercising like that, it feels like, okay, well, you're burning all that glucose so the glucose isn't going in and wreaking havoc on your system. Are you saying now mechanistically that at this age, I guess like you either,

[Peter Attia]

you can't do volume of workout. I think there's two things going on, right? One, I simply couldn't do. I don't think I could do in. One, I don't think I could do for one day what I did for five years every day.

[Tom Bilyeu]

Just too taxing on the system.

[Peter Attia]

It's just too difficult. Like I don't have the physical capacity to go. Like today, if I went out and ran 10 miles, I'd be beat for the rest of the day. Like that would be my day. Whereas I had done that before six in the morning every day. And I was just getting started. So I simply can't do what I used to be able to do. So I think that's just a big part of it. But also, as we age, for reasons that are not entirely clear, we do become less metabolically healthy. Our mitochondria become less efficient, our muscles become more insulin resistant. Part of that's driven by hormones, part of that's driven by enzymes. I mean, we know that testosterone is going down. My testosterone is actually quite low. You know, I'm sitting here kind of on the fence contemplating, should I really start testosterone replacement therapy? Because my testosterone has kind of been in the crapper for a few years. But I know, give me crapper.

[Tom Bilyeu]

What, what number?

[Peter Attia]

Oh, I sort of hover in the 400 nanogram per deciliter range and I've kind of been there for a few years.

[Tom Bilyeu]

And you've tried to elevate it naturally and can't.

[Peter Attia]

I mean, only in that I'm doing all the right stuff. Like I sleep incredibly well, but my FSH and LH are really at the upper end of normal. In other words, like everything from my brain is doing the right thing. My brain is telling my body to make testosterone, but you know, I'm sort of at the limits of what my body's willing to make right now, which is, you know, probably I'm at about the 20th percentile now.

[Tom Bilyeu]

One time you and I had spoken about testosterone replacement therapy and you said you prefer to do precursors and not. So would you still do the precursors if you do it?

[Peter Attia]

I'd probably start with a precursor or a pre hormone like hcg. I wouldn't use Clomid, which is another one, and give it a shot and see if that could really wake things up. But you know, eventually, you know, I'd probably need testosterone. But even that, like, even if you restored my testosterone levels to what they were in my teens or twenties, I'm not sure that that would be remotely sufficient to address the metabolic changes that have occurred in me. You know, I probably have less hormone sensitive lipase or lipoprotein lipase rather on my muscle cells and more of it on my fat cells. In other words, my body is probably more inclined to fuel partition unfavorably, meaning it's probably more inclined to take energy and put it into fat cells as opposed to direct it towards muscle cells. So all of that is to say there's no way today I could out exercise a bad diet. And as a general rule again, at least if using body composition as the metric, yeah, it's a pretty good, you know, rule of thumb that you're not going to out exercise a bad diet. But there are exceptions, clearly.

[Tom Bilyeu]

Okay, so I want to linger on this idea for a second that because this, the reason that I am really, I've always steered myself towards things that you say is because you have a really deep ability to get to the mechanism of action. And so this idea that a diet is incredibly important in terms of you have to do the right thing to avoid downside, but it's not really going to elevate you. Now we hand over to exercise and exercise is potentially going to now pull you farther forward. But I want to understand why. So is it you talk a lot about in the book stability? Is it just that I'm not going to fall or is there something going on at the cellular level that becomes important?

[Peter Attia]

It's all of the above. So, you know, generally speaking, we think about this through the lens of health span and lifespan. So let's just start with the lifespan side of that and we can even go back and talk about the nutrition piece. Right. So if your nutrition is suboptimal, what does that mean? There are lots of ways your nutrition can be suboptimal. It can have too many calories in it, it can have too few calories in, can have too little protein in it, it can have deficient micronutrients in it. I mean, those are going to be some of the big examples of where nutrition can be off and those will produce different phenotypes. You could be underweight, you can be overweight, you can be insulin resistant, which comes hand in hand with excess nutrition. You can be under muscled, which would be a result of low protein intake. So and then you can have a whole bunch of sort of deficiencies like B vitamin deficiencies and vitamin D, all sorts of nutritional deficiencies that come from not getting the right vitamins and micronutrients. On the exercise side, we can go through the same exercise, by the way, on, on the nutrition side, that mostly impacts lifespan. Those deficiencies disproportionately point towards a shorter lifespan. So as you increase adiposity, you increase, meaning as you get fatter, you increase the odds that you're going to start spilling that excess fat from the safe place that you can store it, which is in your subcutaneous fat cells. As athletic, as aesthetically unappealing as that is, but otherwise metabolically quite inert, you start spilling that into places where fat shouldn't be. Inside the liver, inside the muscle itself, meaning right inside the muscle cell around the pancreas, around the heart, around the kidneys, around the organs itself is visceral fat. Once you start spilling fat there, all of a sudden your risk of every disease, every chronic disease goes up. And it goes up a lot, right? I mean, we're talking about a doubling of risk of cardiovascular disease, cancer and neurodegenerative disease, especially Alzheimer's disease.

[Tom Bilyeu]

Don't pull past that. So I need to understand this mechanism. So it's, you're filling the fat cells, you're also making new fat.

[Peter Attia]

Ce, not so much you basically.

[Tom Bilyeu]

I'm talking about when it's working well.

[Peter Attia]

Oh no, no, you're just filling the fat cells and the subcutaneous fat cells are accommodating the increase in energy Storage. So again, even though, you know, culturally we don't like that, that means you're getting fatter. Evolutionarily, that's an enormous leap. Step forward. Right. This is what allowed us to basically develop monstrous brains, is the ability to store lots of energy. So we weren't dependent on meal to meal because our brain is by far the most energy hungry part of our body. So you have this organ, weighs 2% of your body weight, consumes 20 to 25% of your energy. Any interruption in energy is going to prevent the brain from working. So in order to evolve very quickly and basically hit escape velocity on all other species, this was our trick. How could we become efficient at storing energy? And fat is by far the most efficient way to store energy. So this is all very good. It only becomes problematic when you live in an environment where there is so much abundant energy that you exceed the capacity of this system to safely store it.

[Tom Bilyeu]

Right.

[Peter Attia]

So the way you can think of it, I think I described it in the book, is a bathtub. If a bathtub that is your. The total depot of all your fat cells, water is, energy is flowing in, there's a little drain that safely drains water out. That's your expenditure of energy. The balance between those two things determines the water level. At some point, if the input is so much greater than the output, you will not only raise the level of water to the point where it's getting bigger, you'll start to overflow. It's that overflow that's destructive.

[Tom Bilyeu]

Right, Right. So does your body store visceral fat without overflow?

[Peter Attia]

No. Visceral fat is part of the overflow.

[Tom Bilyeu]

Okay, so is visceral fat made up of the same sacs that I would find in my subcutaneous fat?

[Peter Attia]

It's. No, it's. It's actually kind of a different location altogether. And it's, it behaves very differently. So visceral fat is far more inflammatory. In fact, that's part of the problem. You know, if we do a DEXA scan on a person, which is how you can measure some of this stuff, you do a DEXA scan on a person that weighs 200 pounds that has 25% body fat. So by definition, based on those numbers, they have 50 pounds of fat. But let's assume that of that 50 pounds of fat, the visceral fat is 5 pounds. So 10% of their fat is visceral. That 5 pounds of visceral fat is wreaking all the damage in their body. The 45 pounds of fat that is not visceral totally inert.

[Tom Bilyeu]

Okay, let me describe it in a layperson's way. So subcutaneous fat is water inside of a water balloon. Visceral fat is water on your sweatshirt.

[Peter Attia]

Yeah.

[Tom Bilyeu]

And your sweatshirt now is just fucking wet and nasty.

[Peter Attia]

Yeah. Think about the bathtub analogy, right? The, the subcutaneous fat is the water in the bathtub. It's totally fine. The visceral fat or peripancreatic or intramuscular or intrahepatic fat is when it gets out and starts leaking through your floors.

[Tom Bilyeu]

It's the same stuff.

[Peter Attia]

It's the same stuff.

[Tom Bilyeu]

Just one is in its rightful container and the other it's just glommed onto something.

[Peter Attia]

That's right.

[Tom Bilyeu]

That is really interesting.

[Peter Attia]

So, for example, in the muscle, what does that fat do that's so destructive? Impairs the signal of insulin. Not to get terribly detailed, but you like the mechanism, right? Insulin hits a receptor called the insulin receptor. That insulin receptor triggers a cascade, a chemical cascade in a muscle cell that tells a glucose transporter to move up to the cell and allow glucose to come in. That's the way it's supposed to work. When you have fat inside the muscle cell, that signal gets broken. So that's what the, that's the first sign of insulin resistance. And the body says, hey, I need to get rid of this glucose. I need to get this glucose into the muscle. That's where we store glucose. I can't. I need more and more insulin to do this. And eventually you run out of ways to do that. So initially you can make the glucose go away, but you need more insulin. Eventually, all the insulin in the world doesn't do it. The glucose goes up. That's called type 2 diabetes.

[Tom Bilyeu]

Okay, so how do I overwhelm that system? If I have a binge night on a Saturday and I'm going ham on the ice cream, am I going to overwhelm the system or do I have to fill the fat cells first? Is it basically speed or quantity?

[Peter Attia]

So two separate things there. So if you're just having one binge night, eating ice cream and stuff, you're, you're binging, you know, you've got glucose and fat, and you may, you may well dispose of those things. Fine. It depends on your incoming state. So if you're a relatively healthy person, an insulin sensitive person, a night of bingeing really isn't going to cause any trouble. Certainly nothing long term. Right. What we're really talking about is the chronic result of doing that. And so the glucose piece and the fat piece are slightly different. The glucose piece is very tightly regulated. You know, if you consider the difference between a person who doesn't have type 2 diabetes and someone who does, it's literally only the difference of one teaspoon of sugar in the blood. That's the, I mean it's a remarkable difference in terms of how subtle it is. That's how tightly the body wants to regulate glucose. So when the body can't do, when the body can't regulate glucose, that becomes type 2 diabetes. Long before that's happened, you've usually started exceeding your storage of fat. And it's that excess fat that spills out of the bathtub that is making the body dysfunction around glucose regulation.

[Tom Bilyeu]

I've recently heard that it's more dangerous to be a lean diabetic than to be an obese diabetic. Do you agree with that?

[Peter Attia]

The data absolutely suggests that that is the case.

[Tom Bilyeu]

Okay, so if I'm a lean diabetic, then what that predicts is that my water balloons are very small and they just can't take much water and so they keep spilling back out. Spilling back out, spilling back out. So if I'm a lean diabetic, I probably have a ton of fat around viscera.

[Peter Attia]

Yep. And that doesn't translate to much weight on the scale. Cuz you don't need much of visceral fat, peripancreatic fat, intrahepatic fat, you don't need much of it inter in total mass to cause absolute metabolic destruction.

[Tom Bilyeu]

Okay.

[Peter Attia]

And so that's why the lean insulin resistant, the lean person who's metabolically unhealthy has the worst outcome.

[Tom Bilyeu]

So interesting man. So, okay, before reading your book, I would have come in and said, all right, let me just look at the person, I'll ballpark you. If they are lean, they're almost certainly fine. And if they are obese, they for sure, no question they have a problem, metabolic disorder, they're in danger. I get the feeling from reading your book, while that may sometimes be correct and maybe directionally at the population level it's fine, but that an individual actually can be fat and healthy and that a lean person can effectively have the blood of somebody who's morbidly obese.

[Peter Attia]

Yeah, you're absolutely right. At the population level we can look at things like BMI and make general broad statements, but at the individual level, to do anything other than ask the question specifically about that person is to do a disservice. And you're right. Up to a third of people who meet The BMI criteria for obesity. They are metabolically healthy and their life expectancy is the same as a lean person.

[Tom Bilyeu]

Jesus. Okay, so when I read that in your book, I actually had this impulse. I'm ashamed and I would never act on it, but I had the mask mandate impulse of like, you can't tell people that like you, you're just better off telling them that being fat is going to kill you. Don't be fat.

[Peter Attia]

Well, so this is where nuance comes into consideration. Everything I just said is more about lifespan, but let's talk about health span.

[Tom Bilyeu]

Okay.

[Peter Attia]

There are reasons to not be obese that goes beyond premature cardiovascular disease, cancer, et cetera. Think about the impact it has on joints.

[Tom Bilyeu]

So it's not necessarily going to shorten your life if you're metabolically healthy, but there are still other consequences.

[Peter Attia]

That's right. Got it. Okay.

[Tom Bilyeu]

Joints. Just because I'm carrying so much weight.

[Peter Attia]

Yes. Every time you take a step while walking, your knees are experiencing approximately three times your body weight in terms of force.

[Tom Bilyeu]

Jesus.

[Peter Attia]

When you're running, it's about eight times your body weight. So losing weight has a very non linear effect on your joints. And similarly gaining weight in the negative direction has a very non linear effect on joints. There's a reason that now I'm not that psyched about running the way I was when I was 25 pounds lighter. I was 25 pounds lighter. My joints handled it effortlessly. Today, I don't know, I'd probably get away with it, but I'd have to really reduce my volume and frankly, I just choose not to. I much prefer to get my cardio doing things that aren't having impact on my joints. Yeah, we don't want to dismiss the orthopedic causes of, you know, reduced morbid, reduced, more reduced mobility and weight plays an absolute role on that. Furthermore, I don't want to suggest that body composition doesn't matter. Lean mass absolutely does matter and it's really what people should be focusing on. So this gets back to the point of, you know, the reason I'm not a huge fan of sort of population based metrics like BMI is they just don't contain enough information. Right. Like a very, very muscular individual will could have a BMI of an obese person. So obese is defined as a BMI of 20, pardon me, of 30. Overweight is a BMI between 25 and 30 is overweight. I think my BMI is like 28. So I'm, I'm closer to obesity than normal weight. But I'm not based on body composition.

[Tom Bilyeu]

Yeah, so body composition, really not watching. He's, he's got some muscle on him, this kid.

[Peter Attia]

No, I mean I'm like, you know, just. I'm a relatively normal, healthy guy and that's what.

[Tom Bilyeu]

By what metric do you consider your physique?

[Peter Attia]

Normal.

[Tom Bilyeu]

Like the normal person in America.

[Peter Attia]

Yeah, maybe not. Maybe not.

[Tom Bilyeu]

Heavy.

[Peter Attia]

Yeah, sure. So anyway, my point being when we look at our patients, we. I don't know my patients. BMIs. I couldn't care less. I want to know how much visceral fat they have. I want to know how much total body fat they have. I want to know their bone mineral density. And the metric I probably care most about or at least as much as bone density and visceral fat is something called appendicular lean mass index and fat free mass index.

[Tom Bilyeu]

What is that?

[Peter Attia]

So appendicular lean mass index is take the total amount of muscle mass in both arms, both legs in kilograms, divide it by your height in meters squared. You get number. That number we rank on a nomogram and we care what that percentile is.

[Tom Bilyeu]

Why? Arms and legs.

[Peter Attia]

Arms and legs. Well, we do two. So you do appendicular lean mass index, which is arms, legs, and then we do fat free mass index, which is all non fat mass of the body. And you do the same calculation. Each has a pro and con. The fat free mass index has the advantage of including all the muscle in the body, but unfortunately it includes stuff that's not muscle. It includes organs. The appendicular lean mass index has the advantage of being a very good proxy for muscle mass in those locations because they don't have organs in your arms and legs. So we do both. And they usually give concordant answers, but sometimes they're a little discordant and we have to evaluate them. Discordant, meaning they have different percentile predictions, but we want to see people at or above the 75th percentile for those two muscle mass metrics. And again, you don't have to be super. That doesn't mean you're super jacked. Right. Like, you know, a super jacked person is off the chart on those things. But again, no one would accuse me of being super jacked. I think I'm at the 95th percentile. So we're. This is not a, this is not a standard. That is unreasonable. And the reason we care about that is the, the evidence that if you look at a person whose alemi is greater than the 75th percentile, that's one

[Tom Bilyeu]

of the ones you were just describing.

[Peter Attia]

That's the appendicular lean mass index. And you compare them to people below the 75th percentile. The mortality difference in those people once they reach their mid-70s is a staggering difference. So in one study, if you looked at people who were 75th percentile or higher, their 10 year survival from the age of 72 was 80%. If you looked at people who were below that, their 10 year survival was 50%. That's a pretty big difference.

[Tom Bilyeu]

When you take on a new client that is coming to you specifically for longevity reasons, do you start with looking for signs of degradation, the damage that they've done, or are you prescribing the things that they ought to do?

[Peter Attia]

No, we start, we want to, we want to get as much baseline information as possible. So everything from your family history in excoriating detail.

[Tom Bilyeu]

Because this is going to tell you about the, what you call the horseman in the book.

[Peter Attia]

Yeah. What are your region of death? That's right. What are your risks? At least as your genes would set us up to believe? Obviously, lots of blood work, body composition information, functional testing. So mitochondrial function, VO2max, which is peak aerobic strength and movement. Those are really big, big buckets. And we have very specific test that we use for each of those things. The strength and movement tests are tests we've designed over the past several years. And they're, I think in many ways some of our best work really, because they're, you know, we had to come up with this stuff on our own because nobody else really had a test that we felt was as predictive of, you know, what we wanted to believe. So it's doing a whole bunch of that type of testing and using all of that to basically come up with something we called the Longevity Risk Assessment, the lra, which is a rank order of all the things that are a threat to their longevity. There's basically seven things that are a threat to how long you live and how well you live. And we just sort of rank them out and get to work. And that's when you start to get to prescriptive. What are the seven cardiovascular disease or the diseases of atherosclerosis? So cardiovascular and cerebrovascular disease, cancer, neurodegenerative diseases, inclusive of all dementias, accidental deaths, including automotive accident.

[Tom Bilyeu]

What do you look at for that

[Peter Attia]

fall risk as you get older? Yeah, so it's basically falls, automotive and overdose. So that would, by the way, include people who are using illicit drugs.

[American Express Announcer]

Right.

[Peter Attia]

If you're using illicit drugs nowadays, there's a very good chance you're running the risk of getting spiked by fentanyl. Right. Last year, over 100,000 people died by accidentally ingesting fentanyl because it's so cheap.

[Tom Bilyeu]

And so people are putting it into other drugs.

[Peter Attia]

Yeah. Basically, drug cartels are now using synthetic fentanyl as a filler and drugs because it's insanely cheap.

[Tom Bilyeu]

Okay.

[Peter Attia]

Then you get into cognitive sort of physical decline. So orthopedic injury and physical decline. And then there's usually some special one that'll show up that's specific to an individual. So, for example, you know, someone might have hemochromatosis or something like that, or someone that is. Yeah, just a genetic disorder of, like, iron metabolism. Or someone might have, you know, low kidney function or something like that. Once you kind of rank order those risks, that's what determines the getting to work part. So now you start to get prescriptive. How do you go about mitigating those risks? So then you'll take on a period

[Tom Bilyeu]

of time, what are the things that you start looking at? So if I said, hey, the person you want to talk to, you can't ask them any questions, but I can give you any reading you want, would you go immediately? There's seven things we look for in the blood or.

[Peter Attia]

Yeah, blood testing is very helpful, but it has lots of blind spots. There's no one test that offers us everything. So blood testing, for example, will give us great insight into your risk of cardiovascular disease, pretty good insight into your risk of dementia.

[Tom Bilyeu]

What are you looking for there? I'm gonna guess glucose.

[Peter Attia]

Yep. You're certainly looking for all things that pertain to metabolic health, all things that pertain to lipids and lipoproteins, inflammation, things like homocysteine.

[Tom Bilyeu]

What would you look for for inflammation? C reactive protein.

[Peter Attia]

Yeah, C reactive protein, interleukins, things like that. You also look for. Again, all the lipoproteins factor into both cardiovascular disease and dementia really fast.

[Tom Bilyeu]

I want to go back to inflammation. This is the one that scares me the most. When I was a kid, you could write on my skin just by scratching me, and it would welt up. I ice my wrist. In fact, this is where you and I first crossed paths. I was icing my wrist for 15 years. You had me try keto, which we'll definitely talk about your change of perspective on that. That changed my life. And by introducing healthy fats, my inflammation plummeted. But I still. I've never done a C reactive protein test. If you see C reactive protein in the blood, do you know that. Oh, that's coming from. Or is it just like.

[Peter Attia]

Okay, it's very nonspecific. Yeah, yeah. So very, very high levels of C reactive protein, which we often see almost assuredly don't constitute pathology of concern. It's usually an acute illness.

[Tom Bilyeu]

Really?

[Peter Attia]

Yeah. So normal C reactive protein level is less than 1. If, if I get a patient's blood back and it's 12, I'm calling them and I'm saying, hey, were you sick around the time we do this blood? And they're almost always saying no, but I got sick the next day. Or yeah, I'm just, I was just coming off a bad cold.

[Tom Bilyeu]

Somebody on a standard American diet won't have sp.

[Peter Attia]

Not, not to that high. Usually what I'm more concerned with is the person who's got a C reactive protein of two and a half that never goes away. There's something going on there and it could be diet related, it could be autoimmune, it could be cardiovascular. It's very difficult to know. So again, the problem with most of the biomarkers around inflammation is the profound non specificity of them.

[Tom Bilyeu]

When did your. So if my arrogance around diet started to dwindle with your book, when did your conviction around diet is going to be the answer to everything? What began to shake that?

[Peter Attia]

I think just kind of in the process of writing this book and getting deeper and deeper into the data. I don't know, circa 2011, 2012, where I even went on a whole rant about the non importance of exercise relative to nutrition. And by the way, I acknowledge up front the irony of me writing this because this was still back in the days when I was exercising three or four hours a day. But I sort of chalked that up to look, I have an addiction and I do this and I love it and it's like a hobby, it's like a passion. Like I would do this if it were harmful. But like don't look at me and think you need to be doing this. All you need to be doing is, you know, controlling your diet. So, so it just became impossible for me to ignore the, the literature on

[Tom Bilyeu]

exercise and what, what's the thing like you saw grip strength is tied to a massive decrease in all cause, mortality, stuff like that. Like what are the big indicators?

[Peter Attia]

It's the entire spectrum of it. Right. So it's the experimental literature, the epidemiologic literature, the mechanistic literature, but what's it all saying?

[Tom Bilyeu]

Muscle matters. Like if we had. I know you hate the. I did this whole note taking session about how you hate like people that don't get into the nuance. And then I was like, my counterpoint to that is if you can't distill this stuff.

[Peter Attia]

No, look, I would say high cardiorespiratory fitness and high muscle mass and strength are more predictive of a long life than anything else we know.

[Tom Bilyeu]

Say those again.

[Peter Attia]

High cardiorespiratory fitness.

[Tom Bilyeu]

Yes.

[Peter Attia]

VO2 max.

[Tom Bilyeu]

Okay.

[Peter Attia]

High muscle mass, high strength.

[Tom Bilyeu]

The amount of muscle.

[Peter Attia]

The amount of muscle. Although I would argue it's more strength. And we just see a very tight correlation between strength and muscle mass.

[Tom Bilyeu]

Okay.

[Peter Attia]

Within reason.

[Tom Bilyeu]

Interesting.

[Peter Attia]

That is more predictive of a long life than any other metric we have.

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[Tom Bilyeu]

Okay, so now we're going to get to. I'm going to test this at the fringes. I don't know if you know who Dr. William Lee is, but I just had him on the show and I was barraging him with questions about sumo wrestlers and he made an assertion that I found just impossible to wrap my head around, which is that a sumo wrestler may be perfectly healthy. And I was just like, how the fuck is that? What that tells me is that I could ask you and get a prescriptive answer to the question, how do I get obese in a healthy fashion?

[Peter Attia]

So I can't speak to sumo wrestlers. I don't understand anything about them. I don't know. But on its face, it's possible. Right? And based on what we just talked about.

[Tom Bilyeu]

So they can be as long as they're hella strong.

[Peter Attia]

As long? Well, no, no. As long as they are metabolically healthy in their obesity. There's no question that a sumo wrestler is profoundly obese.

[Tom Bilyeu]

Right?

[Peter Attia]

And it's not like just muscle mass. So a sumo wrestler is extremely high in muscle mass, is extremely high in strength, is also extremely high in fat, if they also happen to have high cardiorespiratory fitness, which I'm guessing they do to do what they do, provided all that extra fat isn't creating a metabolic problem.

[Tom Bilyeu]

Okay, let's. Let's define that. So they're not leaking out. So they don't have this.

[Peter Attia]

They don't have insulin resistance.

[Tom Bilyeu]

They're able to uptake their.

[Peter Attia]

They can diagnose glucose just fine. They're.

[Tom Bilyeu]

And the reason that matters so much is because if you don't, you're getting. The glucose is sticking to things.

[Peter Attia]

Yes. So that's. That's half of the equation. So half of the damage. This is a bit of an oversimplification, but half of the damage is the excess glucose is causing a lot of sticking around and it's damaging small blood vessels. The other half of the problem, maybe even a bigger half of the problem, is the excess insulin that is trying to put that glucose away is causing damage to larger blood vessels. And also it's a growth factor that is constantly in the on switch feeding tumors. Cancer would certainly be the biggest concern you would have there. And that's probably why after. After smoking. Obesity is the second most prevalent environmental

[Tom Bilyeu]

trigger of cancer because obesity is a signal that you've got your body in grow, grow, grow mode.

[Peter Attia]

Well, obesity is often, though not always, accompanied by high signals of growth and inflammation, which gets back to, you know, are you a metabolically healthy or unhealthy obese person? If you're metabolically unhealthy and obese, that means it's by definition accompanied by high growth factor, high inflammation, high glucose, and all of those things are destructive to your health.

[Tom Bilyeu]

So is the fat becoming inflammatory because it sends out a hormonal signal or

[Peter Attia]

it sends out inflammatory signals when it's not in the fat cell, when it's not in the right fat cell, when it's not in the subcutaneous fat cell.

[Tom Bilyeu]

Got it.

[Peter Attia]

So those visceral. Those fat droplets that are around the organs are sending out inflammatory signals.

[Tom Bilyeu]

So when we're looking at an obese person just to beat this point to death, really, we're just concerned about. I'm gonna guess, given that you're obese, that you're probably leaking fat into the system that is becoming visceral fat, which is just loose. Using the water balloon analogy, it's just loose fat and sticking to things that it's not supposed to. Causing distress in the liver. I know. Can cause scarring.

[Peter Attia]

Absolutely. Causing damage in the liver that. Yes. Can absolutely lead to scarring and ultimately cirrhosis if it doesn't go a go, go away. Which is the leading cause of liver transplantation is fat accumulation in the liver not related to alcohol ingestion.

[Tom Bilyeu]

Yeah.

[Peter Attia]

And getting into the pancreas poisoning the beta cells, making it harder for them to even make insulin. So further exacerbating the problem of high levels of glucose. So, yeah, but the problem is when you're looking at that person with your naked eye, you don't really know it.

[Tom Bilyeu]

Okay, very interesting. All right, so back to strength. Getting back to our sumo wrestler. So we would have to look for things to see if this is fat in a healthy way. Can I say protective instead of healthy?

[Peter Attia]

Sure.

[Tom Bilyeu]

Maybe I just have something emotional I still need to work through with obesity. But it feels like the reason that a lean diabetic is in a far more problematic state is it does not have the defensive mechanism of, hey, this terrible diet that you're eating is causing the leakage of fat. And when you're obese, it's like, hey, we got you. You can pump the system full of fat. We can store it appropriately. All as well. So the obesity then, to a point, will be protective.

[Peter Attia]

It seems that obesity, to a point, is the safest place to put excess

[Tom Bilyeu]

energy, which you're better off not consuming.

[Peter Attia]

Yes. But if you are consuming it, you're way better off storing it in subcutaneous fat cells and getting bigger than you are, just letting it dissipate into. In other words, you're better off having a bigger bathtub that's full than having a smaller bathtub that's draining water onto your floor and down your heat ducts.

[Tom Bilyeu]

Okay, let me ask you another question while I get. As we age, we're probably not going to be able to do it. Is there any damage being accumulated to a Michael Phelps in his early 20s eating 10,000 calories but burning 10,000 calories through exercise?

[Peter Attia]

Yeah, great question. Probably not in the short run, and probably not if, upon ceasing all of that activity, the energy expenditure returns back to an appropriate level.

[Tom Bilyeu]

So as long as the body's using it, you're fine.

[Peter Attia]

Yeah. Now, again, there might be a behavioral challenge there. It might not be an accident that a lot of former athletes who are, you know, basically eating as much as is humanly possible to support their energetic needs when they're young, struggle to maintain health when they get older because the habit of still. I mean, truthfully, Tom, I think I still struggle with this. Like, I mean, I'm not in a position now where I can just eat all the time, and yet I think there's a part of me that's still kind of wired to want to. Right. But again, when you're not exercising six hours a day, you can't so. And I remember, you know, even when I was young, my parents just watching with complete befuddlement as I would. I was just constantly eating. I mean, it didn't matter. Like I would tear through ice cream. I was just always like, it didn't matter. It just didn't matter. I was an eating machine. And it was freakish for people to watch. They couldn't believe it. And yet I was rail lean. Right. And they said, I remember my parents saying is like, you know, they're like, you better be careful. Like one day you're not going to be able to eat like this.

[Tom Bilyeu]

Yeah. That is the lamentations of the old looking at the young. Yeah, No, I definitely get it. Okay, so. So if you. Maybe the data already shows this, but if you had to guess or base it on the data, why does strength matter so much? Is it that cardio fitness means your heartbeat's lower when you're not exercising? And the differential between how much you exercise and thus speed it up, but the amount of time you spend in that really slow resting heart rate, that's the deal, is it? You're going to say all of the above, but like grip strength, so I'm not falling. I don't know what else. Storing amino acids in muscle. Yeah.

[Peter Attia]

So I think there's several things going on. So let's talk about the limitations of the exercise. So the limitations of the data are their data are only as good as things that we can measure. So you know what hemoglobin A1C is?

[Tom Bilyeu]

Yes.

[Peter Attia]

Okay, so hemoglobin A1C for people listening is a blood test. You get that in a snapshot, gives some prediction over what your blood glucose has been doing for the past few months. So in that sense, it's what is called an integrator. Right. If you think back to calculus, for people who took calculus, the integral is the area under the curve. It's the total ups and downs. It incorporates everything that's happened. And so in this case, hemoglobin A1c is an integral function of the last three months of your eating, at least as it pertains to glucose. Doesn't tell you anything about fat, protein, overall calories, doesn't tell you any of that stuff, but gives you a pretty good indication of how your body regulated glucose. Okay. Integral functions are not common in biology, unfortunately. I had a recently very interesting guest on my podcast and we talked about how HDL cholesterol may be an integral function for recent triglyceride levels. So the fluctuations in your Triglycerides. And we know that lower is definitely better, becomes an inverse correlate with HDL cholesterol. So the higher your HDL cholesterol might suggest lower previous levels of triglyceride. So that's kind of interesting. That has not been validated, but it's an interesting hypothesis. But for the most part, we just don't get great integral functions. It turns out VO2 Max is a really good integral function of how much cardio training you do. So VO2 max. Have you ever had a test done?

[Tom Bilyeu]

I have not.

[Peter Attia]

But do you know how it works?

[Tom Bilyeu]

I think so. So you run all out and then you go slow, get your heart rate back to 100, run all out again.

[Peter Attia]

Well, that's how you would train for it. But the test is done on either on a treadmill or a bike. Those are pretty much the only two ways to do it. You have a mask on and you're pushed. So you get a warm up and stuff, but then you're basically pushed until

[Tom Bilyeu]

you fail, where you're like, I have to jump off the treadmill.

[Peter Attia]

Yes, got it. And what's happened? What?

[Tom Bilyeu]

They're measuring sprinting. So they're trying to figure out.

[Peter Attia]

No, no, it's not, it's, it's at the end, it feels like you're sprinting, but they'll, you know, if you have two max test might take 10 minutes. They're gradually working you up and watching your consumption of oxygen rise. So this mask is measuring how much oxygen you consume because it has a little oxygen sensor on it, so it knows the flow rate of oxygen that you're putting in. And it's measuring the concentration coming out. And it's, it says, okay, right now you're consuming one liter of oxygen. So you and I sitting here right now are consuming 3 or 400 ML of oxygen per minute. Very little. If pushed to your max, you might be ten times that.

[Tom Bilyeu]

Whoa.

[Peter Attia]

The fittest athletes in the world, you know, will get to 20 times that they have the capacity to use so much oxygen. So that's what the VO2 Max test is. It is measuring your maximum consumption of oxygen. The higher that level, the longer you're going to live. There is no number, there is no biomarker. There's no finding in all of biology that is more predictive of a person's length of life than that specific number. And the question is why? And I believe the reason is VO2 max is such a potent integrator for what you have to do to have that Number you aren't born with that number being high. There's clearly a genetic component to that number. You know, the highest people in the world ever measured are born with a great potential for it, but they won't get that potential without training. And the training you have to do to get that is pretty hard. So what the, what this tells you is that that type of training is what's really valuable. The same is true with strength. When you compare very strong people to very weak people, you see almost as high a prediction of longevity as you do with high VO2 max to low VO2 max. And again, it's important that we are strong for all the reasons you said. It helps you prevent falling, it helps you stand up, it helps you do all of these things that matter. But I think the reason it's telling us you're also going to live a long time is because it tells us what you had to do to get there. When we see that the top 10% of people with grip strength compared to the bottom 10% of people with grip strength have a 70% less chance of getting Alzheimer's disease and a 70% chance of dying from Alzheimer's disease, it's not because grip strength by itself protects your brain. It's because those people, by definition are doing so much more physically. And it's the doing part that is protecting their brain.

[Tom Bilyeu]

Man, this is very interesting. So let. I'm going to ask it. So let's imagine a world where we have just insane AI with VR. Do you think that I would be able to stimulate my brain in a way that. Because people talk about for staving off dementia, like dancing is the thing.

[Peter Attia]

It's a thing.

[Tom Bilyeu]

So can I obfuscate the need for the physical part if I'm stimulating the brain, or is it like, nope, you're not doing the things you would need to do to make your heart. And again, I don't know if it's resting heart rate becomes the thing that's good because if it really is just the thing you have to do and not the outcome of the thing. Right. Can I fake it?

[Peter Attia]

Probably you would get some benefit in a. If you did this as a thought experiment where let's assume we can truly above your neck replicate the experience, that's probably giving you some of the benefit, but I don't think it's giving you the majority of the benefit. So the muscle acts like an endocrine organ. So when it is put under the appropriate stress, it is releasing myokines, right? It is releasing hormones that are having a beneficial value. For example, bdnf, brain derived neurotropic factor is being released and providing effectively nutrition to neurons. So you actually have to do the thing to get it, not just thinking you're doing the thing. Also, let's not forget all of the other benefits of exercise, such as the metabolic benefits. So we talked about all of this business around insulin resistance. Well, the number one cure for insulin resistance is exercise. That's why those sumo wrestlers can be morbidly obese by most definitions and still potentially be quite insulin sensitive because of how active they are. And then of course we get into the structural piece of this. Right. Which is what good is it to have a brain that works if your body actually does not?

[Tom Bilyeu]

Yeah. Or vice versa.

[Peter Attia]

Yep.

[Tom Bilyeu]

For that matter. Okay, so ketogenics was something, it really was transformational. And as I discovered ketogenics through you, I'm very curious to hear you no longer feel the same that you did. What changed?

[Peter Attia]

Well, it's a broader topic, I think around that of dietary restriction. So I think my aperture has just widened significantly. So you have to take a step way back and ask the question, how does one, what are the ways in which one can change their diet? So, so let's come back to your example in a moment because I think if I recall, when you went on a ketogenic diet, it wasn't in an effort to lose weight.

[Tom Bilyeu]

No.

[Peter Attia]

Yeah. So let's put your case aside for a moment and instead discuss it through the lens of how most people think about ketogenic diets, vegan diets, pick your diets, it's usually some form of energy restriction. So I think initially I was like, most people are pretty myopic about my views of energy restriction. And over time that thinking evolved into saying, look, there are really broadly speaking three strategies to reduce intake. One strategy is to just directly fixate on the reduction of energy intake. That's called caloric restriction. So bodybuilders are a great example of this. Right. Like they really know how to weigh and measure every single thing they're eating. And they certainly understand during an anabolic phase, this is how much energy I need. During a catabolic phase or cutting phase, I need this much. And they've got this down to a science. And it's really remarkable.

[Tom Bilyeu]

I mean, it's a science optimized for the reduction of fat.

[Peter Attia]

That's right. That's right.

[Tom Bilyeu]

And maintenance of muscle.

[Peter Attia]

That's exactly right.

[Tom Bilyeu]

So longevity.

[Peter Attia]

That's right. So, so, but, but let's be clear. Like, I don't think there's a better example of any type of person on that's figured out how to control intake up and down and to produce a perfect result with respect to that esthetic.

[Tom Bilyeu]

Well said.

[Peter Attia]

And for most people, that's really hard to do. It's hard to do because you can't really ignore it. Like, you can't just eat without thinking. You always have to be paying attention to what you're doing. But it is the most direct way to go about getting the results you want. So that's method one. Method two says, how about I don't pay attention to what I'm eating or when I'm eating, but I pay attention. Pardon me? How about I don't pay attention to what I'm eating or how much I'm eating, but I just pay attention to when I eat. So that's called time restriction. People call that intermittent fasting. And if I make the window in which I eat small enough, I will reduce energy intake in total. So if I said to you, you know, you can only have one meal a day, chances are you are going to lose weight. Now, people thought that, well, there must be something magical about intermittent fasting beyond the caloric reduction. But that turns out to not be the case. It's been tested in several studies now, and it's clear that if you eat 2000 calories in one sitting, it's no better or worse for you, at least from a weight perspective, than if you eat 2000 calories spread out over the course of a day. It's probably worse for you in another way, though, which is you're a little more likely to lose muscle mass because you won't be able to get the right amount of amino acids.

[Tom Bilyeu]

I don't want to derail your point, but we are going to have to talk about autophagy because I intermittent fast like a fiend.

[Peter Attia]

Great. 365. Yep. Okay, so then we get to the third method of of caloric reduction, which is the use of what's called dietary restriction. So here we pick things within the diet and we cut them out. And the more restrictive that is, the more likely it is to produce an energy reduction and therefore the more likely you are to achieve the goal of weight loss. So the glib example I always give is if you went on the no lettuce diet, you would not lose an ounce, Right? Right. It's simply not restrictive enough. If you went on the only potato diet, you would lose an insane amount of weight. You simply couldn't eat enough potatoes to maintain. Now the, that's not a healthy diet. Right. No one would think that the all potato diet is going to produce an ideal health outcome. But you will lose a lot of weight. Right? So keto is simply a very. For a restrictive form of that diet.

[American Express Announcer]

Diet.

[Peter Attia]

And many people lose a lot of weight on a ketogenic diet because they are limiting so many things. Right. They're limiting so many carbs. It's also for many people much more satiating. So it actually readily reduces their hunger and so they simply don't want to eat more. So they have fewer food choices and they don't want to eat as much. But you can gain weight on a ketogenic diet if you eat a lot. You have to be careful because you're generally eating more energy dense foods on a ketogenic diet.

[Tom Bilyeu]

Diet.

[Peter Attia]

And I've seen lots of people blow up on ketogenic diets because they somehow think it's a license to eat as much fat as they want. Not the case. So now let's talk about. So, so that's. That sort of coming to that conclusion made me realize, oh well, there's nothing really magical about any particular diet when it comes to energy balance. But now each of these diets has their own trade offs around other metrics of health.

[Tom Bilyeu]

Health.

[Peter Attia]

So for example, we talked about the importance of protein. Protein is I think the most important of the macronutrients. I know everybody wants to argue about fat and carbs, but I think the, the game is won and lost with protein. And you know, the recommended dietary allowance of protein is unfortunately very low. So there's. Most people are being told to eat 0.8 grams per kilogram of body weight and that's literally half what you need to be eating.

[Tom Bilyeu]

Whoa.

[Peter Attia]

Yeah.

[Tom Bilyeu]

That's the amount of protein for body mass that I carry or ideal body

[Peter Attia]

mass, total body weight. Yeah.

[Tom Bilyeu]

So if I at 6 foot weighed 250 pounds, I'm going to be wanting to eat something like 1.6x that in protein in kilograms.

[Peter Attia]

So yeah. So if you were, if you weighed, if you were whatever 200 pounds, I would want you consuming at least 160 grams of protein and maybe closer to 200 depending on your demand and depending on your age and depending on the type of protein you're getting. So a lot of different diets, let's pick two that I think one has to be, they're doable but you have to be careful about getting enough protein. So let's start with a plant based Diet. So plant based diet, by definition you can't have any animal protein. So all of a sudden you're doing away with the best form of amino acids. You know, one could argue that when we eat animals or animal protein, it is a more pure synthesis of the amino acids that are coming from plants, right? So like a cow, all it's eating is plant, but you eat a cow or like venison is one of my favorite things, right? So I'm eating wild venison from Hawaii that only eats grass, and yet it's the richest source of amino acids I can sink my teeth into. In other words, its digestive system, its metabolism is doing this remarkable thing I can't do, which is turning grass into the richest, densest source of protein. If I want to go back and eat the grass, it's fine, but I just have to acknowledge I'm going to have to eat a lot more of it because it's not a great source of protein. So the bioavailability of plant protein is about 70% that of animal protein and it's not as rich in the most important amino acids. So when we have patients who are plant based and they say, oh, do I have to give up my plant based diet? I say, not necessarily. And if it's working for you in all other ways other than this, then there's a workaround here. But the workaround requires you being very deliberate about your protein quantity. Another example is you. So we're going to come back to the case that you just said, which is, what about people who are intermittently fasting? Do they have to, you know, is that a bad thing? Is it a good thing? Well, it depends. But if a person is intermittently fasting, you're going to see a lot of muscle loss unless they're very thoughtful about their protein intake. So, you know, if a person's intermittently fasting, 16, 8, you can generally get away with it because in eight hours you can get usually at least three good servings of protein. But we have a lot of people who are intermittently fasting and they're only eating two meals, no snacks. They can't come close to getting the right amount of protein in because you can't have, have. Let's just say you're on the 160 gram a day program. 80 grams twice in your day is not going to cut it because you can't put 80 grams to work. It's too much protein for the body to utilize.

[Tom Bilyeu]

Peter man, this is so different than how I live.

[Peter Attia]

Well, no, but think about it like, bodybuilders are very thoughtful of this. Right. If you look at bodybuilders, they're kind of.

[Tom Bilyeu]

We debunked all the, like, six meals a day, and you're saying no. Like, I actually do need to break it back up in a smaller piece.

[Peter Attia]

If you're optimizing for muscle mass, yes. And it can't be too, too small. So this is where it gets really crazy.

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[Peter Attia]

If you're eating really small amounts of protein, like 20 grams at a time, you're not going to get muscle protein synthesis because the liver is going to. The liver basically takes first dibs on the protein and undergoes gluconeogenesis. It's just going to make glucose out of protein. So if you just trickle tiny amounts of protein in, you're not getting muscle protein synthesis.

[Tom Bilyeu]

I'm turning it into glucose. It's a really inefficient process.

[Peter Attia]

Yeah, you're just. The liver is turning it into glucose. If you eat tons of protein, and the limit, based on the literature, seems to be somewhere between 40 and 50 grams in one sitting.

[Tom Bilyeu]

Okay.

[Peter Attia]

Once you exceed 40 to 50 grams in one sitting, the excess just goes into gluconeogenesis.

[Tom Bilyeu]

Huh. Wow. Okay, this is very fascinating.

[Peter Attia]

So if you're trying to get 140 grams a day, you really need to optimize it by four times 40 and.

[Tom Bilyeu]

Wow. Okay. So amazing. This is amazing. I'm always game to change. Okay, so I'm breaking my protein up 4 by 40. If 160 is my goal, what period of time do I need to put between them? Because I would be happy to do that. Like it. I'm.

[Peter Attia]

What's your feeding window? What do you like to eat? When to.

[Tom Bilyeu]

When, Man, I. I usually keep it tight, like four or five hours max.

[Peter Attia]

Okay. So if you really want to do it that way, then you're going to have to have.

[Tom Bilyeu]

Well, I'd only want to do it that way if I need to.

[Peter Attia]

Well, but, but, but I'm saying, like, like, if that's working for you, from A weight management standpoint and a total caloric.

[Tom Bilyeu]

I'm a freak of discipline. I will never accidentally gain weight. You don't have to worry about that with me. What you have to worry about with me is right now I believe that autophagy is necessary to avoid cancer. I don't want to die of cancer, so I intermittent fast to make sure that I'm in autophagy.

[Peter Attia]

But there's no evidence that 20 hours of fasting is sufficient to induce autophagy.

[Tom Bilyeu]

Yeah, see, I thought there was, man. I thought autophagy kicked in at like, like 15, 16 hours.

[Peter Attia]

But mice will die in three days of not eating.

[Tom Bilyeu]

Well, that's bad.

[Peter Attia]

Yeah. So in other words, like we're just. It's apples to oranges. We have. No.

[Tom Bilyeu]

I mean, do we know where it kicks in for humans?

[Peter Attia]

No, because we don't have biomarkers for autophagy. My intuition, which might be as useful as a warm bucket of hamster vomit, is that it's probably three to five days, three to four days maybe.

[Tom Bilyeu]

Do you do any prolonged fasting?

[Peter Attia]

I don't anymore.

[Tom Bilyeu]

Wow.

[Peter Attia]

And I'm not opposed to it. Like, I would probably still do.

[Tom Bilyeu]

You know, if you were diagnosed with cancer, what would you do?

[Peter Attia]

Yeah, I would probably get back to fasting.

[Tom Bilyeu]

More evidence based or just throwing everything at it.

[Peter Attia]

Mechanistic.

[Tom Bilyeu]

Yeah. Give me the mechanism.

[Peter Attia]

Deprivation of growth factors.

[Tom Bilyeu]

Yeah, very interesting.

[Peter Attia]

Also, selective sensitization of cancer versus non cancer cells during chemo. Right. So there is some evidence from Valter Longo's work that when you're undergoing chemotherapy, doing so in a caloric deficit can be beneficial because the cancer cell is differentially and disproportionately stressed by caloric restriction and then the normal cell. And therefore you're. Because remember chemo, like the magic of chemo is not that it kills cells or kills cancer cells, it's that it selectively kills cancer cells. Anything can kill a cancer cell. It's how do you kill a cancer cell and not a regular cell? So how do you. How do you enhance the spread between those two? And it might be that caloric restriction is a way to do it and it renders the cancer cell even more susceptible. And at the same time that you're hitting it with chemo, it becomes more likely to die at the expense of the healthy cell. That's, that's the mechanism. And there is some data to suggest that that's the case.

[Tom Bilyeu]

Okay, so autophagy we know is going to kick in at much long, we hope is kicking in at much longer periods. Deprivation can still help with cancer from a growth factor.

[Peter Attia]

Remember, you also kick in autophagy with exercise. So if you're looking for another. Absolutely. What is autophagy? Right, autophagy.

[Tom Bilyeu]

Self eating.

[Peter Attia]

Well, yes, yes, yes, but what. It's occurring in nutrient absence. And there's a great way to induce cellular energy reduction, which is exercise. When you exercise, cellular energy goes down. That's why exercise increases AMP kinase activity just as fasting does. So you don't want to underestimate the benefit of exercise in tricking the cell into thinking it's nutrients are scarce.

[Tom Bilyeu]

Okay, then what kind of exercise? I'm gonna guess it has to be the kind that I hate the Most. And if VO2 max is the under the curve revealer, it's what we were talking about. Very high intensity, period of rest, very high intensity.

[Peter Attia]

Well, that's how you train. VO2 max. But that.

[Tom Bilyeu]

Isn't that what I have to do?

[Peter Attia]

No, because that should only be 20% of your cardio volume. 80% of your cardio volume should be steady state and moderate intensity.

[Tom Bilyeu]

Yeah. Okay, the 80%, I like that a lot better. Interesting.

[Peter Attia]

That's zone two, as we call it. And that's done at a level where you could carry out a conversation if you had to, but you don't want to.

[Tom Bilyeu]

Right?

[Peter Attia]

That's the litmus test.

[Tom Bilyeu]

That is a perfect description. Okay, so going back to protein. So maybe in fact, no, you're saying just flat out. The intermittent fasting is probably not helping you at all. And if anything, it's probably making it hard for you to get protein and spare your muscle. You need to spread this out. You spoke in kilograms, which really threw me off.

[Peter Attia]

That's okay. How much do you weigh in pounds?

[Tom Bilyeu]

185.

[Peter Attia]

Okay, so 160 to 180 grams per day. So four meals at 40 to 45 grams is perfect for you.

[Tom Bilyeu]

Okay. Spread out over ideally as long as possible.

[Peter Attia]

And to be clear, these don't have to be meals. Like two of my four.

[Tom Bilyeu]

45 grams of protein. That's a fucking meal.

[Peter Attia]

It's not though. Think about it. Like, what is that, 200 calories?

[Tom Bilyeu]

It's like a chicken breast.

[Peter Attia]

It's. Yeah, that.

[Tom Bilyeu]

I mean, you don't consider that a meal?

[Peter Attia]

That's a rounding error. No, for me, like I'm doing. I'll do like. I have these venison sticks that are 10. Like a little jerky. Venison.

[Tom Bilyeu]

Bought or made?

[Peter Attia]

They're actually now bought. You can now buy them.

[Tom Bilyeu]

I Like that?

[Peter Attia]

Yep. Okay. So each one is 10 grams of protein and 50 calories. And I will have five of those as a snack. There's 50 grams of protein right there with 250 calories. Like it's nothing.

[Tom Bilyeu]

Okay, what about, are they highly processed? Anything to avoid there? No problem.

[Peter Attia]

Because these are the cleanest things on the company. They're made by a company that I'm involved in.

[Tom Bilyeu]

So I mean, I love the most, obviously as a guy that only gets involved with things that I care about, I think are real.

[Peter Attia]

So they called Maui Nui venison.

[Tom Bilyeu]

Okay.

[Peter Attia]

These are, this is a type of deer called Axis deer that are invasive to the state of Hawaii. And so they're harvested there in the most humane manner fashionable, which is what allows the animal to be completely stress free. So they're harvested by sniper at night, under night vision and.

[Tom Bilyeu]

Whoa.

[Peter Attia]

Yeah. So if you think about it like harvesting an animal is a very stressful thing for an animal. Like if you're thinking about how a cow is harvested.

[Tom Bilyeu]

Yeah.

[Peter Attia]

Even if it has the most wonderful life, you know, it's grass fed, it's out in a pasture, it's not inside. Like all of that might be great and it is certainly better than the alternative, but the very end of its life is still quite stressful.

[Tom Bilyeu]

This is a moral thing or does this moral.

[Peter Attia]

No, I believe, I believe it impacts the quality of the meat. Right. So think about the cortisol levels that are surging through that animal's body right at the time of its death.

[Tom Bilyeu]

Yeah, but from an evolutionary standpoint, everything got eaten. Oh, yeah.

[Peter Attia]

No, no, that's not a moral question. I'm saying from a health perspective.

[Tom Bilyeu]

Yeah, but I'm saying you're a lion. The gazelle you're chewing on is freaking the fuck out as you eat it alive. So there's no way that can have some major.

[Peter Attia]

No, I think it actually probably has an impact on taste more than anything else. The other thing is it's very hard. I mean, this is more of an argument of why I love wild game is wild game eats the best plants, the best feed. Right. So when you go to the grocery store and you're buying, you know, a regular grain fed steak, it's not eating what it evolved to eat. Like it's. You kind of want things that are as close to eating what they evolved to eat. And you know, for deer that's like, that's basically grass.

[Tom Bilyeu]

Right.

[Peter Attia]

So anyway, these things are processed in a way that basically has nothing in them. Right. So you're just. I'm just getting pure protein.

[Tom Bilyeu]

Yeah. I don't want to derail us, but this is really interesting. So you snipe the deer at night using night vision goggles. So it basically dies in its sleep.

[Peter Attia]

It dies very instantaneously. Yep. Dies instantaneously. Stress free. Free.

[Tom Bilyeu]

And so interesting. How did you find out about these guys?

[Peter Attia]

I met the founder of the company five, six years ago and we just immediately became friends. I became completely fascinated by the problem that they were trying to solve, which was how, you know, the Hawaiian government is trying to eradicate this species because it is destroying the island. So this is a species of deer that was brought to Hawaii in the 1950s for hunting, but it had no predator. It was brought from India, where its only predator was the tiger. You brought it to Hawaii, it had no predator and it has now run amok. So it is kind of destroying three islands of Hawaii.

[Tom Bilyeu]

Finding a way to do this sustainably now so that they can keep having them.

[Peter Attia]

The goal is by 2030 to have it be sustainable. Right now, they are still not able to do it sustainably. In other words, right now the deer are still growing at a rate that is too significant.

[Tom Bilyeu]

Jesus. Headshots.

[Peter Attia]

Yes.

[Tom Bilyeu]

Interesting.

[Peter Attia]

Wow.

[Tom Bilyeu]

I don't know why I find that so fascinating, but that's very interesting. Okay, so back to protein intake.

[Peter Attia]

Right? So point is, you could have a whey protein shake.

[Tom Bilyeu]

You can wake up. I'm like, chomp, chomp into the venture.

[Peter Attia]

Not necessarily like, I mean, again, it depends on when you like to exercise, for example, so.

[Tom Bilyeu]

So I should exercise fasted. Is that the point of that?

[Peter Attia]

It depends. If I'm going to exercise first thing in the morning, I do it fasted. If I'm going to wait a couple of hours, I'll have a protein meal first.

[Tom Bilyeu]

But it doesn't matter because I've always heard that you've got so much glucose if you're eating and now you're just going to get fat and you're never going to lose weight. It doesn't matter.

[Peter Attia]

No. So. So I generally prefer to exercise fasted. But if the workout is getting pushed till later, a couple hours later, I'm going to have something before. Not because I need to, but because I want to make sure I spread out those protein servings enough. So at least two of my protein servings aren't meals. They're like, again, the jerky is not a meal, it's a snack. And then like a whey protein shake again, 40, 50 grams of whey protein in Some, you know, cashew milk.

[Tom Bilyeu]

Would you. I'm willing to stomach the venison snacks and. Or chicken breast and. Or eggs. Eggs, Yep.

[Peter Attia]

Great.

[Tom Bilyeu]

Cool.

[Peter Attia]

Love them.

[Tom Bilyeu]

So if I'm willing to eat the amount of protein that I need in eggs, venison, whatever, would I still do a protein shake?

[Peter Attia]

Not necessarily. No, not at all.

[Tom Bilyeu]

And do you. Cause I have developed slowly over time a deep aversion to anything that's processed. So I'm trying to get as close to biting.

[Peter Attia]

That's fantastic.

[Tom Bilyeu]

The walking animal as possible.

[Peter Attia]

Absolutely. Yeah. That's great.

[Tom Bilyeu]

Okay, so, but you.

[Peter Attia]

You're.

[Tom Bilyeu]

And then you.

[Peter Attia]

And then you would have. And then you would have like, kind of two meals. Right. So I'll probably also have, like, my lunch would be a salad with chicken breast or salmon. And then my dinner. Dinner is the easiest meal to hit your protein target. Right. Like, that's like falling off a log.

[Tom Bilyeu]

Just because it's typical to eat a steak, you're gonna have whatever you're gonna have. Talk to me. Red meat meat, white meat.

[Peter Attia]

Again, I think it matters less. The color of the meat matters much more. The source of the meat matters much more. About how that grass fed.

[Tom Bilyeu]

Grain fed.

[Peter Attia]

Yeah. And. And how close can you get it to an animal that's in its natural state? Truthfully, it's much easier for me to get wild game that's red meat. Like, I much prefer elk and Axis deer, both wild game that either I'm killing or someone I know is killing.

[Tom Bilyeu]

And it's the wild that's the important part.

[Peter Attia]

Yeah, it's an animal that's eating in the environment. It's. It's an animal that's not contained.

[Tom Bilyeu]

Right. And the contained is problematic, largely because of the diet that we know they will need.

[Peter Attia]

Yep.

[Tom Bilyeu]

Okay. How much meat. How much of your protein comes from meat by percentage?

[Peter Attia]

I don't know. I'd have to figure it out, but

[Tom Bilyeu]

clearly the majority, because the one thing I've always.

[Peter Attia]

Like Greek yogurt, by the way, so that's another thing that's a hard left.

[Tom Bilyeu]

So Greek yogurt has a lot of protein.

[Peter Attia]

It does, actually. It's quite high in protein.

[Tom Bilyeu]

Eat it because of the taste. Probiotics.

[Peter Attia]

Just another way to get protein in, to diversify a little bit from boredom or.

[Tom Bilyeu]

Diversity matters.

[Peter Attia]

Yeah, just some diverse. No, no, just for me, diversity matters. Like, I like to mix things up and. And it's just. Again, it's just a function of time. Like, maybe I don't have time to make an omelette. Right. Now and I'm. I got a quick call I got to jump on so I can scarf down a bowl of Greek yogurt with some nuts in it.

[Tom Bilyeu]

This seems impossible.

[Peter Attia]

It does take too good.

[Tom Bilyeu]

No, it sounds amazing. I feel like the way that I live right now would take a lot more discipline than what you're describing. I'll be interested to see if that's true in practice. Okay, so let's fit eggs into the mix here. I'd love to get an idea knowing that individual. There's a lot of individual variability here. In fact, we should probably talk about saturated fat at the individual level. The one thing in my diet it. I do not at all pay attention to how much saturated fat I eat and go out of my way to consume it, but I make zero attempt to avoid it. And because I don't check my blood levels nearly enough, I am always a little hesitant to push my exact diet onto people. Do I need to worry about saturated fat?

[Peter Attia]

Potentially, yeah. Saturated fat can increase your synthesis of cholesterol. It can also, with enough of it being consumed, the liver can sense the amount of saturated fat and basically shut down the clearance of cholesterol, meaning the. The bringing of cholesterol into the liver.

[Tom Bilyeu]

Can I quote Peter Attia on cholesterol in the book Outlive? If you haven't read it, I highly suggest it. He said your total cholesterol number is about as meaningful to dying from heart disease as your eye color.

[Peter Attia]

That's right.

[Tom Bilyeu]

Right. So you're bringing up cholesterol. So some something matters.

[Peter Attia]

Something about cholesterol matters. But not the total number. Right. Total cholesterol is again, not a particularly relevant number. Apob, which is the constant, which is a measurement, a laboratory measurement, that is the concentration of lipoproteins that carry cholesterol into arteries. That's what you should care deeply about. But when someone says, what's Your total cholesterol? 200 milligrams per deciliter. Who cares? Doesn't mean anything.

[Tom Bilyeu]

But there is a type of cholesterol that is carried in a certain.

[Peter Attia]

Well, so cholesterol, for the most part, that 200 milligrams per deciliter is your total cholesterol. Is divided into three types of lipoproteins.

[Tom Bilyeu]

Has a different carrier.

[Peter Attia]

No, that 200 comes is the aggregation of approximately three lipoproteins. High density lipoprotein, low density lipoprotein, and very low density lipoprotein. So if you look at your lab, you get. You get a blood test done. If it's done correctly, a lot of them are not. But if it's done correctly and they do a direct measurement of LDL cholesterol, you will be able to add up the VLDL cholesterol, the LDL cholesterol, the HDL cholesterol, and the sum of those three will equal the total cholesterol. So if the total cholesterol is 200 and the HDL cholesterol is. Is 70 and the VLDL cholesterol is 20, the LDL cholesterol will be 110.

[Tom Bilyeu]

Yep.

[Peter Attia]

And of those three numbers, we would say the most important insight you could get would be to take total cholesterol, subtract HDL cholesterol, and that number is called non HDL cholesterol. That number starts to become a pretty good predictor of risk.

[Tom Bilyeu]

So total cholesterol, because those are damaging in some way.

[Peter Attia]

Yeah. That's now telling you the total cholesterol content of LDL and vldl, and those are the destructive lipoproteins. Now, an even better number is not how much cholesterol is contained in those two things, but how many of those two things do you have? And that's what's captured by apob.

[Tom Bilyeu]

Can you explain that more?

[Peter Attia]

So each of those lipoproteins, the VLDL and the ldl, have a protein wrapped around them. That protein is called apolipoprotein B100, which is a very sexy name. It's abbreviated APOB. So if you measure APOB, because LDL and VLDL have one and only one apolipoprotein B100 on them, the APOB number is the concentration of those two particles and the gradient of that. The more of those particles you have, the increase, the greater the probability that those particles are getting into your artery walls.

[Tom Bilyeu]

Got it. So the. The number of those do matter. And so if I just subtract out my hdl.

[Peter Attia]

Subtract your HDL from your total cholesterol, you get the cholesterol concentration of those two particles. But. And that's predictive of risk. But what's more predictive of risk is the number of those particles, which is apob.

[Tom Bilyeu]

How do you. I don't know if it's gonna be fruitful, but there's something in that math that I'm not following. So if I got back my cholesterol count and I look at them, I'd be able to tell of my 200. Let's say 110 are the two that are bad, but there's some total number. It sounds like you're.

[Peter Attia]

It's a separate measurement. You wouldn't impute it from those cholesterol.

[Tom Bilyeu]

You just have to go to apob.

[Peter Attia]

You have to get the apob measured. Got it. It's another laboratory measurement.

[Tom Bilyeu]

Understood. Understood.

[Peter Attia]

That is, unfortunately, rarely done.

[Tom Bilyeu]

Is it? Can you just ask your doctor, give me an apob measurement?

[Peter Attia]

Absolutely. Okay. It's a relatively inexpensive test. It's about people just depending on the test. It's somewhere between 5 and $20.

[Tom Bilyeu]

Do they not do it because they disagree with you or they just don't know?

[Peter Attia]

They don't know what it is?

[Tom Bilyeu]

Troubling.

[Peter Attia]

Very.

[Tom Bilyeu]

Okay, so, in fact, we should talk at least briefly about this idea. So in the book, you talk about medicine 3.0 versus medicine 2.0. Medicine 2.0 is all about curing. Medicine 3.0 is all about prevention. How do we.

[Peter Attia]

I would call medicine 2.0 more about treating than curing.

[Tom Bilyeu]

Okay. Fair.

[Peter Attia]

It's largely not curative. Right.

[Tom Bilyeu]

Very good distinction. Okay, so if you were going to give me the. The little toolkit of medicine 3.0, what. How would you begin to bundle that? Like, what are the. The things that I should be going towards?

[Peter Attia]

Well, again, to your point. So medicine 3.0 really says we've reached the limits of what medicine 2.0 is good for. Medicine 2.0 is really good at curing acute problems. So it's really good at curing infections, traumas, acute issues. It's really bad at treating chronic problems. Cancer. Cancer, you know, recurrent heart disease, neurodegenerative disease, type 2 diabetes. It's really bad at treating those things. And therefore, all it really does is prolong the period of time you have those things. And I go through a lot of explanation in the book as to why that strategy is not the right strategy. So living longer is not accomplished by living longer with disease. Living longer is accomplished by living longer without disease. Once you realize that, you inevitably come to the obvious conclusion that a new type of medicine is needed, which must be focused on extending the period of time you do not have disease. And that word is prevention, which has been bastardized to mean virtually nothing because everybody talks about prevention, but it has no meaning. Right? So true. Prevention has to start very early. True. Prevention needs a set of tools that medicine 2.0 doesn't participate in. Medicine 2.0, which is the medical system that every one of us who's trained goes through, is largely a pharmacologic playbook. Now, you're going to get people who sit here and say are from all Pharmacology is bad. Medicine is bad. No, no, that's not true at all. Pharmacology is wonderful. Pharmacology has done amazing things in medicine 2.0, and we would want to use all of those pharmacologic tools as needed in medicine 3.0. But it's literally, you know, one fifth of the equation. Where is nutrition, where is exercise, where is sleep, where is emotional health? Those things are also needed to delay the onset of chronic disease. And none of us got trained in those tools, so. So if a doctor is going to help their patient with those other four tools, they're going to have to learn about it outside of training.

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