Why Diet Won't Increase Your Lifespan! (Longevity Myths) | Peter Attia Pt 2

Summary

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Podcast Summary: "Why Diet Won't Increase Your Lifespan! (Longevity Myths)"

Podcast: Tom Bilyeu’s Impact Theory
Guest: Dr. Peter Attia
Date: May 29, 2023

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Episode Overview

In this insightful and myth-busting episode, Tom Bilyeu continues his deep-dive interview with longevity expert Dr. Peter Attia (author of Outlive). This second part explores the truths and misconceptions around lifespan and healthspan, the limited impact of diet on extending life, the essential role of emotional health, and the importance of identifying your individual health risks—what Dr. Attia calls “the Four Horsemen” of chronic disease. The conversation also covers cutting-edge interventions, nuanced views on supplements and drugs, the uncertain role of the microbiome, and actionable advice for maximizing both the quality and quantity of your years.

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Key Discussion Points and Insights

1. Cholesterol, Lipids & Genetics Demystified

• Dietary Cholesterol ≠ Blood Cholesterol:
  • Most dietary cholesterol isn't absorbed; it's mostly excreted ([02:49]).
  • “Eating cholesterol has almost zero bearing on your cholesterol levels in your blood.” – Dr. Attia [03:16]
  • The real determinants are genetics and how your body traffics cholesterol.
• Lipoproteins 101:
  • Cholesterol is a cargo; lipoproteins (LDL, HDL) are the “boats” ([03:40]).
  • LDL ("bad cholesterol") is better called "bad lipoprotein," as the cholesterol molecule itself is the same in LDL and HDL ([04:20]).
• Atherogenic Risks:
  • Only low- and very-low-density lipoproteins containing APOB can get stuck in artery walls, triggering inflammation and plaque buildup, leading to heart attack ([07:24], [08:47]).
  • “When an APOB particle goes into the artery wall, sometimes it stays in there. When it stays in there…bad things begin to happen.” – Dr. Attia [07:24]

2. The Calorie Quality Debate

• A Calorie Is Not a Calorie—for Longevity:
  • Equal calories from different sources don’t yield the same health outcomes ([10:31]).
  • “I clearly don’t expect the guy on 2,500 calories of Twix bars to live as long as the person on 2,500 calories of good food.” – Dr. Attia [11:19]
  • Satiety, energy expenditure, and health outcomes differ based on food quality, even at isocaloric intake.

3. The Overlooked Pillar: Emotional Health

• Holistic Longevity:
  • Attia highlights three pillars: physical, cognitive, and emotional health ([12:23]).
  • Emotional well-being and relationships are central to a life worth prolonging:
    “If that house is in disarray, I would make the argument that living longer is a curse, not a blessing.” – Dr. Attia [16:42]
• Personal Growth & Vulnerability:
  • The last chapter in his book details Attia’s own struggle and growth in emotional health, emphasizing the need for personal example in medical advice ([13:57], [14:11]).

4. Why Quality of Life Is as Vital as Quantity

• Thought Experiments on Immortality:
  • Attia & Bilyeu discuss whether indefinite life would be worth living without relationships or purpose ([17:23]–[21:04]).
• Why Motivation Matters:
  • “Your ability to do [the habits that drive healthspan/lifespan] is highly predicated on your relationship with yourself.” – Dr. Attia [24:03]

5. The Four Horsemen of Death

• Major Chronic Disease Categories:
  1. Atherosclerotic disease (heart disease, stroke)
  2. Cancer
  3. Neurodegenerative disease (dementias, etc.)
  4. Metabolic disease spectrum (from insulin resistance/fatty liver to type 2 diabetes – the “amplifier” of the other three) ([30:46]–[32:05])
• Personalizing Prevention:
  • Know your family history and personal risk factors to focus efforts ([25:30]–[26:21]).

6. Limits of Diet and Exercise in Some Risk Profiles

• Genes vs. Lifestyle:
  • Some conditions like high Lp(a) are highly genetic; lifestyle mitigates but does not remove risk ([34:18]–[34:26]).
• When to Use Drugs:
  • Diet alters blood lipids only modestly for most; sometimes drugs are the best/only option for high-risk patients ([38:54], [39:59]).
  • Drug selection and side effects (e.g., statins vs. PCSK9 inhibitors) are discussed, with focus on patient-specific trade-offs ([37:13]–[43:34]).

7. Cutting-Edge Therapies and Experimental Approaches

• Rapamycin and the Fight Against Aging:
  • Attia takes rapamycin (off-label) for its potential anti-aging effects, relying on animal data but prepared to revise his approach as new evidence emerges ([42:20]–[45:34]).
  • “I’m steeped reasonably well in the literature, and I have a strong enough conviction that the way we’re dosing it…has a much higher probability of being valuable than not.” – Dr. Attia [45:11]
• Cancer Advances:
  • While cancer survival rates have seen only slight improvements in recent decades, immunotherapy and combination therapies offer new hope ([49:07]–[52:47]).
  • Early detection and aggressive screening increase odds of survival ([53:32], [54:06]).

8. The Microbiome: Promising, but Uncertain

• Current Clinical Usefulness?
  • “Anybody who says they know what to do with [the microbiome] is probably trying to sell you a supplement.” – Dr. Attia [55:45]
  • While microbiome effects are real, actionable interventions remain elusive and unproven ([55:42]–[56:37]).
• Skepticism of Supplements:
  • Supplements have weak oversight; Attia applies extra scrutiny and sees more risk/uncertainty than with pharmaceuticals ([59:30]–[59:52]).

9. Pragmatic Longevity: Individualized, Not Prescriptive

• No One-Size-Fits-All Answer:
  • “There is no sentence I can give any person to tell them what their prescription is.” – Dr. Attia [77:23]
  • Focus should be on the weakest link in your habits—sleep, exercise, metabolic health—which varies person to person.

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Notable Quotes & Memorable Moments

• On emotional health’s neglected importance:
  “If that house is in disarray, I would make the argument that living longer is a curse, not a blessing.” – Dr. Attia [16:42]
• On calorie quality:
  “A calorie is not a calorie, for sure, right...The calorie is a calorie debate I think is kind of a silly one.” – Dr. Attia [10:31]
• On finding your risk factor:
  “You really have to figure out what of the Horsemen is coming for you, what agent of death, from a family history, genetic makeup, lifestyle, all of that.” – Tom Bilyeu [25:30]
• On supplements vs. drugs:
  “The supplement industry is such a filthy, disgusting industry that even though I take supplements, I stress more about sourcing those than I would ever stress about sourcing pharma.” – Dr. Attia [59:31]
• On actionable strategies:
  “Let’s get the diet right first… Diet is really hard to get right... For most people, it’s not sufficiently reduced in fat enough to have a meaningful impact on their lipids. And therefore, if we want to get APOB low enough... we’re going to need a drug.” – Dr. Attia [40:39–41:59]

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Important Timestamps

• Cholesterol misinformation busted: [02:49]–[09:38]
• “A calorie is a calorie” debate: [09:53]–[12:05]
• Emotional health and meaning: [12:05]–[17:23]
• Immortality thought experiment: [17:23]–[21:04]
• Four Horsemen named and explained: [30:46]–[32:05]
• Personalizing prevention: [25:30]–[26:21]
• Cancer: detection & optimism: [49:07]–[54:26]
• Microbiome skepticism: [55:42]–[60:55]
• Supplements vs. pharma: [59:30]–[60:28]
• No one-size-fits-all answer: [77:23]–[78:44]

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Actionable Takeaways

• Know Your Genetic Risks: Get appropriate screenings, especially for family history (e.g., Lp(a), APOE4).
• Healthspan ≠ Lifespan: Focus not just on adding years to your life but quality to your years—physical, cognitive, and emotional.
• No Magic Bullet: Lasting change is through compounding daily habits; beware of miracle solutions.
• Be Wary of Overhyped Microbiome/Supplement Claims: Current science isn’t actionable; prioritize interventions with proven outcomes.
• Prioritize the Weakest Link: Fix sleep, then exercise, diet, and so on—what’s most broken is most important.
• Personalize Your Plan: Medicine and longevity are as individual as your fingerprint.

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Connect with Dr. Peter Attia

• PeterAttiaMD.com – Weekly research-backed longevity updates

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Transcript

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[Dr. Peter Attia]

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[Tom Bilyeu]

Hey guys. Welcome back for the second part of this two part episode featuring the longevity expert Dr. Peter Attia. In this segment, Peter weighs in on the calorie debate, breaks down the emotional side of longevity that nobody talks about, and reveals the four horsemen of death and how to figure out which one you need to watch out for. As a side note, we've just launched our exclusive Impact Theory subscription service that takes your podcast listening experience to a whole new level. So if you're tired of ads cutting into your favorite episodes, at the best part, we have got you covered. With our extra Impact Theory subscription, you can listen to Impact Theory completely ad free. 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 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. Sign up today. I'm Tom Bilyeu and welcome to Impact Theory. Okay, so if we know what we're trying to do is delay the onset of these diseases, you talk about that in the book. That basically the thing that centenarians have in common is that they probably were able to delay the arrival of heart disease dementia because you say this cancer that these things are building for oftentimes decades, that you can see heart disease in teenagers, which is pretty crazy. So these are people that have probably delayed the onset of the early symptoms of that for decades more than the people that die at say 70 or 80 exactly okay, that makes sense. So now then, I want to get to. And we'll stay on cholesterol here for a second. So you talk about in the book that dietary cholesterol does not equal cholesterol in your body. So what does? What causes bad cholesterol being the thing that I'm certainly more concerned about.

[Dr. Peter Attia]

So dietary cholesterol is very difficult for our body to absorb. It has a bulky chemical side chain on it called an ester. And the only way we could absorb it is if we have an enzyme to cut the ester off called the de esterified and bring it in. We don't have much of that enzyme. So most of the cholesterol you eat, such as the cholesterol in, you know, shellfish or eggs, you poop out. Okay, so we should just make sure everybody understands that eating cholesterol has almost zero bearing on your cholesterol levels in your blood. That doesn't mean that your diet has no bearing on the cholesterol in your blood, but your genes play a very significant role in the levels of your blood lipids. So we want to always differentiate between cholesterol and lipoproteins. Cholesterol is the cargo, lipoproteins are the boat. So the term bad cholesterol doesn't actually mean anything. People say LDL is the bad cholesterol. That's actually very inaccurate. Right? Ldl, low density lipoprotein is the boat that carries cholesterol, and LDL is bad. But we should really say LDL is the bad lipoprotein. The cholesterol is in LDL is the same cholesterol in hdl, which people call good cholesterol. So you can see why it doesn't make any sense. Now, every cell in your body makes cholesterol, so 95% of the cholesterol in your body is cholesterol. You made the reason every cell in your body makes cholesterol is because it is one of the most important molecules in the body. If you couldn't make cholesterol, you would have died in utero. And the reason for it is every cell in your body is wrapped in a membrane, and that membrane is made of cholesterol. Most of the important hormones in your body, testosterone, estrogen, progesterone, cortisol, are made from cholesterol. So this hormone is absolutely. This molecule is essential for life. But not every cell can make enough of it. So we have to be able to traffic it between cells. So we have to be able to take it back to the liver. The liver has to be able to package it back out. It has to be able to move around the system. So if your body is like a big city, the superhighway of that body is the blood, the circulatory system. And the circulatory system is made of water. So when you cut yourself, you know, you see red stuff come out. But don't let the hemoglobin and platelets and things confuse you. It's just water with a bunch of red proteins in it. And fat doesn't mix with water. Cholesterol is a fat, it's a lipid. And it doesn't dissolve in water. So we can't just move cholesterol around in the blood the way we move glucose or the way that we move sodium or potassium, those things are dissolving in water. They're called hydrophilic, and they move around freely. Cholesterol is not. It's hydrophobic. It repels water. So that's why we have lipoproteins. We have to have these lipoproteins to move the cholesterol in and out of the body. And that gets to the point of. There are basically these different types of lipoproteins. Some of them are very high density. They have lots of protein and a little bit of fat in them. Some of them are low density, lots of fat, less protein, and some are very low density, virtually no protein and lots of fat or cholesterol. And they have different properties. And it turns out that the low density and the very low density ones are. Are the ones that are atherogenic, meaning they're the ones that promote the destruction of your arteries.

[Tom Bilyeu]

Okay, so something is starting to slowly come into focus for me. So fat in the blood is bad cholesterol or fat?

[Dr. Peter Attia]

Which one do you mean?

[Tom Bilyeu]

I mean fat. So when we talk about if, if I'm understanding what you're saying correctly, there are two times now that fat getting loose has sounded like a problem.

[Dr. Peter Attia]

Well, let's not. So. So fat is rarely floating around the bloodstream for the same reason.

[Tom Bilyeu]

But if a lipoprotein, if the very low density is in indicated because it has very little protein and a lot of fat.

[Dr. Peter Attia]

Well, just when I use fat there, what I'm really referring to is triglyceride and cholesterol. But they're inside the lipoprotein.

[Tom Bilyeu]

Why does it matter that the ratio of protein to fat starts getting low?

[Dr. Peter Attia]

It only matters in that that's how I'm describing why they're difference in density. Got it.

[Tom Bilyeu]

So it isn't that, it is fat that makes them problematic. So what do they do?

[Dr. Peter Attia]

What's problematic is that the low density lipoprotein and the very low density lipoprotein are the only ones that seem to make their way into coronary artery walls or artery walls in general. And they have the potential to get stuck in there. So the high density lipoprotein, no, we don't really have a great sense of it. It's something about apob. So HDL high density lipoprotein doesn't have APOB on its surface. It has something called APO A on its surface. And when a high density lipoprotein goes into the artery wall, it comes back out. When an APOB particle goes into the artery wall, sometimes it comes out, but sometimes it stays in there. And when it stays in there or gets retained, bad things begin to happen. The first of those things is it undergoes a chemical reaction called oxidation. That chemical reaction called oxidation creates an inflammatory signal and that tells inflammatory cells called macrophages or monocytes to come. They become macrophages and they eat that oxidized LDL molecule. That's what kicks off a devastating cascade in which the body, ironically and paradoxically, in trying to fix the problem, creates a catastrophic problem that ultimately leads to the creation of a plaque that if it ruptures, will block the blood supply of the artery and cause a heart attack.

[Tom Bilyeu]

You've got the two types that end up, basically, they have the APOB on them. APOB can get stuck in my arteries. Once it's stuck in my arteries, my body sends a immune response effectively that then ends up creating a problem is that calcification.

[Dr. Peter Attia]

Calcification is the final stage of the body trying to repair the problem. So think of it as the concrete that gets poured on a melting down nuclear reactor. So when you get a CT scan that's like what's called a coronary CT scan to look for calcification, the presence of that calcification, while by itself not problematic, is predictive of something bad that's happened. I describe, I think in the book, calcification is like going through a neighborhood and seeing bars on the windows. The bars on the windows are actually a good thing. They're going to prevent somebody from breaking in, but it tells you what kind of neighborhood you're in.

[Tom Bilyeu]

Yeah, okay. Now that makes a lot of sense going on with my diet. One thing that I'm very curious about, and there's a raging debate online, a calorie is just a calorie

[Dr. Peter Attia]

where, where

[Tom Bilyeu]

do you come down on that in terms of the quality of the calorie? Does it matter if I'm eating terr? Like if you agree that the quality of the calorie matters but I'm still under eating, do I have a problem?

[Dr. Peter Attia]

So the, the, the calorie is a calorie discussion always needs some clarification. Are we talking about with respect to energy balance, are we talking about with respect to nutrition and health, are we talking about with respect to satiety? And so we have to clarify which of those we're talking about.

[Tom Bilyeu]

All I'm talking about ever is longevity.

[Dr. Peter Attia]

So, so then a calorie is not a calorie for sure. Right. So in other words, if you took a bunch of people and put, you know, one group of them on 2500 calories a day of Twix bars and another group on 2500 calories of, you know, one food only lettuce, you know, or whatever, it wouldn't be 2500 calories lettuce, but you know, 2500 calories of venison sticks. Venison sticks. And another group on 2500 calories of some well rounded diet that's, you know, they might all end up with the same weight, they might have a different health quality and they would, I would expect it. I clearly don't expect the guy on 2500 calories of Twix bars to, to live as long as the person on 2500 calories of good food, nor do I expect them to feel the same. So if you're totally, and by the way, they might end up at slightly different weights because of how they feel. And while you may in this experiment control only their intake, you might not be able to control their energy expenditure. So they might actually expend different amounts of energy because of how they feel. So the, the calorie is a calorie debate I think is kind of a silly one because a lot of times people are talking past each other when they're yelling at each other and they don't understand what they're talking about. And so you, you know, we just have to understand, are we talking about pure controlled, you know, calorimetry or are we talking about, in your case, what you're asking about, which is, I think more important, which is healthy.

[Tom Bilyeu]

Okay, so your book goes into something really interesting, which is the emotional side of all of this. So what role does that play? Why does it matter? Yeah. In a book about longevity. I was surprised to see that section. Happy, but surprised Well, I think it's

[Dr. Peter Attia]

not a section that would have appeared in the first five years of my writing this book. Right. Like, you know, we talked about, this book took six, seven years to write. And the first and second versions of this book were very different from the third version, which is the version sitting on this table. And I think when this book started out, it was a book about how to delay death. That was really what the book was about. Like, what do you need to know about heart disease and cancer and Alzheimer's disease and exercise and nutrition and sleep and this drug and that drug to delay death as much as possible. And the book really evolved into what do you need to know to live the best life? And I don't think I could write about that without talking about a very important, albeit difficult to quantify aspect of health span, which is the side of longevity that refers to quality of life, without ignoring, you know, by ignoring emotional health. It's, it's what I consider one of the three pillars of health span. So physical health, right? All the stuff about your body, freedom from pain, strength, flexibility, movement, all those things. Cognitive health, the ability of your brain to work and to stay sharp and, you know, have executive function, processing speed, memory, etc. But then there's this piece called emotional health. And so the last chapter of the book is really about that. And I think that had I not written that, the book would be very incomplete.

[Tom Bilyeu]

So for you, is it about identifying why you do what you do? Is it about the example that you give in the book is you healing your own trauma? What, what is the game there?

[Dr. Peter Attia]

Well, the, you know, there, there's 17 chapters in the book and 16 of them are. I, I think I'm, you know, coming across in some way as an authority, right. Like that's, it's being written as though at least I know what I'm talking about. And I, hopefully I do, but I'm writing it as the physician, and the last chapter is an area where I write it as the patient. So I talk about my journey over the last five or in kind of getting better in this dimension. This was always an area of my life that I think was lacking enormously. And as a result of that, I think I, you know, the book has lots of patient examples, right? The book is written in a, in a, in a scientific way. But of course, you know, you never tell a story without making a point, and you never make a point without telling a story. Well, the last chapter, I just happened to be the patient in it, and that's the way in which I walk through, hopefully a conveying of the importance of paying attention to this.

[Tom Bilyeu]

What I'm trying to figure out, though, is what. What is that a category of? So one thing I talk to people a lot about is meaning and purpose. Talk to people about emotional control. But there's also the angle of there's going to be a cellular result of your thinking. And this is where it starts to get cloudy. And so there are people, I'll let them remain nameless, that I don't interview this type of person because I think they cross the line between thoughts, become physical and getting into. Now we're just making shit up so that you can think something and manifest it, or if you have cancer, you can think it away. And so I want to know, where is that line for you? You felt it important enough to bring it up in a book about longevity. Was it just, though, a quality? Hey, I've told you how to get quantity. Now I want to talk quality. Or is there.

[Dr. Peter Attia]

No, no. I mean, I think there's several things, right, so. So start with the. The question as posed to me by Esther Perel. Have you had Esther on your podcast?

[Tom Bilyeu]

I have. Yeah.

[Dr. Peter Attia]

So. So people listening will be familiar with her. So, you know, Esther posed this question to me many years ago, which is effectively, why would you want to live longer if you're unhappy? And that's such a obvious question. And yet I am amazed, absolutely amazed at how much I interact with people. Because, remember, all I do is interact with people who want to live longer. That's my job. Everybody I'm talking to, everybody who wants to talk to me always wants to talk about how to live longer, how to live better in some way, and yet very rarely are they paying attention to this aspect of their life. What is their relationship like with themselves? How well, as you put it, do they understand themselves? What are their relationships with other people? How well are they able to regulate their emotions? How present are they? What is their sense of purpose? What is driving them all these things? And if that house is in disarray, I would make the argument that living longer is a curse, not a blessing.

[Tom Bilyeu]

It's a bold statement, but push back on it.

[Dr. Peter Attia]

I mean, what's the definition of torture? Right? Let's play a thought experiment. If I said to you, tom, I'm going to grant you immortality in perfect health, so it's not going to be like Tithonius, where I let you live forever, but you age forever, that would be hell. No, no, I'm going to allow you to stay right. Like you are now. You're not going to get one more wrinkle on your face. You're never going to get a disease. Would you take it?

[Tom Bilyeu]

Yes.

[Dr. Peter Attia]

I'm not going to give it to anybody else in your life.

[Tom Bilyeu]

Oh, yeah, I would take that. I'm always shocked that other people, my wife included, wouldn't. I would.

[Dr. Peter Attia]

All right, so let's go one step further. I'm going to give it. No, I wouldn't.

[Tom Bilyeu]

That's so interesting. Do you know how many people you're going to watch die? Wait, I'm making the assumption that's what bothers you. Why wouldn't you take that?

[Dr. Peter Attia]

Well, let's come back to me. I want to keep going with you for a minute.

[Grainger Advertiser]

Okay.

[Dr. Peter Attia]

Okay. So now I'm going to make the. I'm going to give you a different experiment. We're going to do the same thing, but I'm going to put you on a desert island now.

[Tom Bilyeu]

Yep.

[Dr. Peter Attia]

And I'm going to provide everything for you so you're not going to have to worry about finding food. In fact, forget the desert island. I'm going to keep you in this beautiful house and I'm going to somehow keep the lights on and I'm going to somehow keep the food coming in. But there will be no other human on this planet for you to ever interact with, including your wife. Would you take that?

[Tom Bilyeu]

Can I kill myself?

[Dr. Peter Attia]

No.

[Tom Bilyeu]

So I have to live forever like that?

[Dr. Peter Attia]

Yes.

[Tom Bilyeu]

That's the first one where just. What I know about the human psyche breaking in isolation. I. It would be ill advised though. God, I would want to. If you'd let me kill myself at any point, I would take it. But if I can't, it's too dangerous.

[Dr. Peter Attia]

No, of course you wouldn't take it. Right. I mean you. How.

[Tom Bilyeu]

It's not in the course for me. That is not self evident. And if I didn't understand what happens to the human psyche when it's isolated in my life, where I have been isolated for extended periods of time, I have experienced no suffering whatsoever.

[Dr. Peter Attia]

I don't disagree with that. But I think the question is. Yeah. What's the longest period of time you've been isolated?

[Tom Bilyeu]

Yeah, exactly.

[Dr. Peter Attia]

And what is isol to truly me?

[Tom Bilyeu]

Yeah, yeah, yeah. And if I have input, like if you let me keep the lights on and I could have entertainment. I've thought a lot about this. Like how much would that help? But like let's. You saw the movie Castaway?

[Dr. Peter Attia]

Yeah.

[Tom Bilyeu]

Okay. So if I had any glimmer of hope that I could get off that island. I would want to be alive. I would want to try and try.

[Dr. Peter Attia]

That's a totally different story. Right.

[Tom Bilyeu]

So this is what I'm saying is even the hope that I could one day. Recap.

[Dr. Peter Attia]

I'm telling you there's no hope. I'm telling you.

[Tom Bilyeu]

So then I would not.

[Dr. Peter Attia]

But I'm going to let you live indefinitely in this house all by yourself.

[Tom Bilyeu]

Yep.

[Dr. Peter Attia]

Okay. So that's just an extreme example of one dimension of emotional health, which is connection to others. And I'm. I'm telling you that given everything to excess. Oh, and by the way, I'll even. I'll even sweeten the deal, Tom. I'll give you all the money in the world and you can buy whatever you want.

[Tom Bilyeu]

Well, right now. Buy what?

[Dr. Peter Attia]

Oh, you could buy yachts, art, whatever you want. We've got. We're going to have robots that do everything for you, that make everything. And you can't interact with these robots.

[Tom Bilyeu]

I was going to say you complicated.

[Dr. Peter Attia]

The robots are not, they're not going to supplant.

[Tom Bilyeu]

So there's. There's everything could ever want except for humans.

[Dr. Peter Attia]

You can have all the cars, all the yachts, all. Whatever. You're not going to do it. If you really stop to think about it, you're not going to do it because with no connection to another person, it's a meaningless life.

[Tom Bilyeu]

Yep.

[Dr. Peter Attia]

So we could do the same sort of exercise going through all of these different elements of emotional health. And I think if people are really being brutally honest with themselves, they'll realize that if you, you know, if your wife hates you, if your kids hate you, if you're, you know, you're. People around you don't feel good about you and you don't feel good about yourself, and you're not, you know, you don't have a sense of why you're doing what you're doing. I think. I think it's. I think it's a tough. I think it's a tough way to live.

[Tom Bilyeu]

So do you think that people asking that question of how to live longer is in some ways not the wrong question, but it's just so incomplete that you need to address the emotional side.

[Dr. Peter Attia]

I think it's a very understandable question. I can't speak to others, but I certainly, through my own experience, can understand why one would ask that question and why it's something you would want to grasp onto. I mean, I think that for most of us, the thought of not existing is a little if not frightening, certainly very uncomfortable. Non existence is very difficult, only on the backside.

[Tom Bilyeu]

So we all know what non existence is like. Try to imagine what you were like before you were born. So it's possible I'm deluding myself. It's also possible that I really just see this slightly differently. So I have absolutely no fear of not existing if. Yeah, the thought of just not waking up tomorrow only gives me anxiety around. Ooh, did I make sure that I sorted things out from my. My wife? Like, is she going to be okay? Like the thought of something bad happening to her. I don't like that knowing that I'm about to die would change my frame of reference so radically that it would make me immediately behave differently. So definitely a huge part of the way that I behave is predicated on that I have more time. I try to operate. Knowing that it's certainly not guaranteed I could have an aneurysm and keel over and die before the end of this podcast. I'm very aware of that. The reason that this feels so important to me and the reason that I was so glad you included it in the book is that I think the only thing ultimately that matters is how you feel about yourself when you're by yourself. And if you have earned your own respect, I think that's hugely important. I just found it very intriguing that not a lot of people are going to cover that topic in your book and I was wondering if there is. If it's just that, like, hey, make sure that it's worth fighting this hard to stay alive and make sure that you're not just driven by the animal instinct to fight or flight. And basically you have a vision of your mortality that you're running away from, but you're never like figuring out why you live. Or is there also a sense of if you're in that state where you're very stressed out, you're prone to anger, whatever the case may be, you're also shortening your life.

[Dr. Peter Attia]

Yeah, I think it's both Tom and I think that a lot of people are self sabotaging without understanding why. So we have a lot of agency over living longer. I mean, if there's one thing I hope someone takes away from this book, it's how malleable their lifespan is and how malleable their health span is. But you have to do things to get that. As you pointed out at the beginning of the discussion, there is no easy way to do this. There's not a pill or a specific workout or a superfood or a supplement or whatever that's going to make all of this easy. It's a lot of stuff that has to be done over a relatively long period of time. And your ability to do that is highly predicated on your relationship with yourself. And so, you know, having sort of poor sleep habits, poor nutrition habits, poor exercise habits, on some level, has a component or a root in your emotional health. And that's not true for everybody, but it is true for a lot of people. And I see this constantly in my patients, right? I see patients whose own story, whose own narrative is partly an impediment to their actions. And so they're suffering twice. They're suffering in that their failure to take actions or their actions that they're taking, for example, drinking too much are going to actually shorten their life, but they're also going to decrease the joy of their life and the harmony of their life for whatever period they have.

[Tom Bilyeu]

So let's say that we do everything right. Let's say we've got meaning and purpose. We have dealt with our emotional difficulties. We have identified. And this is actually something that's really important that I took away from the book. You really have to figure out what of the Horsemen is coming for you, what agent of death, from a family history, genetic makeup, lifestyle, all of that. Which one is most likely to come and get you? I think that's very important. It might be worth actually recapping who the Horsemen are. We've touched on them, I think all of them, but we didn't name them, is like, these are the Horsemen. Might be worth doing that. But. So you've. You're doing all this. How long can we live? Like, is it really, like, we're already there? It's like 122. And I hope you get there, my friend, and follow the book and you'll get to 122. Or can we actually push this farther

[Dr. Peter Attia]

based on what we have today? I don't see us exceeding the human record for longevity. I think to go beyond that would require a technological breakthrough. So I would never represent that. You know, doing everything to the max with respect to perfect nutrition, perfect exercise, perfect management of the Horsemen through all means necessary, that that's going to get someone to exceed that level. You know, my thinking of this is that, you know, we might have 10 years of stretch, which is a huge amount if you really stop to think about it. Right? If you're, you know, life expectancy is 82, and you make it to 92 instead.

[Tom Bilyeu]

And they're quality.

[Dr. Peter Attia]

Exactly. And that's the point right where I'm really confident we have the capacity to change it is on quality. And you know, I said to you, everybody comes to me on some level and they want to talk about longevity. But when I really probe them, what they really mean is health span. They don't care as much about how long they live. They really care about the quality at the end of their life.

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[Tom Bilyeu]

I care about both, to be really honest. As do I. Healthspan would be. If I don't have that, it's all meaningless. I totally agree with you. I would pay almost any price to live longer. And so, for instance, the question that you asked, like, I would. Even if there was an apocalypse, as long as there were some other people. Even if it killed everyone I knew and loved, which would be brutal, man. Like, I am. I am into my wife in a way most people just are not into their significant other. I can tell by talking to them. And even that I would. If a meteorite hit and it was like, your wife is going to die, but you can live. I'd be like, yeah, I want to live. So my wife wouldn't, though. She's like, if you die, I'm going. That's so interesting. I can't wrap my head.

[Dr. Peter Attia]

I mean, it depends on my kids, but. But yes, if my wife and kids were not on this earth, I wouldn't want to be on this.

[Tom Bilyeu]

But what would happen if. God forbid, Peter, God forbid, I don't have kids because. Partly because I am so afraid of how devastating it would be if they died. But if they died, would you want to die?

[Dr. Peter Attia]

I mean, again, I hope I never have to contemplate that. But if I lost all of my kids, yeah, I'd have a hard time probably wanting to go on.

[Tom Bilyeu]

Wow. Wow. I get it, man. Look, it is. I have seen people go through it. It is an unbearable thing that I can't believe life asks of anybody, but despite knowing how bad that hurts, and I would not want to go through it. I don't know, man. And look, of course I might get so rocked. I'm just saying here, from an emotional sobriety standpoint, where it is just the thought exercise, I don't understand people's response to be like, yeah, just take me out.

[Dr. Peter Attia]

But let's go back to, I think, what's the more germane point, which is you want quality of life and length of life. I hope what comes across really clearly in the book is those are not mutually exclusive. And what I really would like people to understand is if you pursue them both, you get them both. In fact, if you just focus on health span, if you just focus on preserving cognition, having the most physically robust body possible as you age and pursuing emotional health, you are guaranteed to get lifespan benefits as well.

[Tom Bilyeu]

Okay, so talk to me about the Horsemen. Let's name them.

[Dr. Peter Attia]

So there's four. Three of them basically account for the majority of death in the first world. One of them directly doesn't account for that much of the death, but indirectly probably accounts for the most of it. In other words, it's the amplifier of the other three. So the big three are the diseases of atherosclerosis, so heart disease and stroke. Second one is cancer. Third one is neurodegenerative diseases, inclusive of all dementias. So that includes Alzheimer's disease, Parkinson's disease, Lewy Body dementia, vascular dementia, etc. So those, those three, really, they, they show up a lot on death certificates. They kill a lot of people. The fourth one is more of a spectrum. It's not a single disease, but it's the spectrum that goes from hyperinsulinemia to insulin resistance, fatty liver disease, all that metabolic stuff we talked about, all the way out to type 2 diabetes. And again, not a huge number of people's Death certificate says NAFLD. Type 2 diabetes a little bit, but not, not staggering. But when you're on that spectrum, the further you get towards the type 2 diabetes side of that spectrum, you're just doubling your risk, essentially. Of all the other three horsemen, do

[Tom Bilyeu]

you think that metabolic disease is causative? Like is basically every non traumatic death, Is it downstream?

[Dr. Peter Attia]

No, it's neither necessary nor sufficient, but it is causative. So you can have causality without necessity and sufficienc. So let's take an obvious example. Smoking. Is smoking causatively related to lung cancer? 100% like, meaning there is a causal relationship between smoking and lung cancer. But 15% of people who get lung cancer never smoked. I don't know the number, but many people who smoke don't get lung cancer. So similarly, metabolic disease is 100% causally related to the other diseases. But not everybody who gets meta. Not everybody who's metabolically ill is going to necessarily succumb to those diseases. You could die of something else. And not everybody who succumbs to those diseases had metabolic disease.

[Tom Bilyeu]

Okay, that's really interesting. There's at least one example you give in the book. I'm not sure where you put your own story, but you scored a 6 on the calcification scale. Very young, 35. And then Anahat O', Connor, who we bizarrely both know, you know him way, way, way, way, way better than I do. But I had the good fortune of meeting him. He scored like 126 or some ridiculous thing. So is that the kind of example where you guys were both relatively healthy but have this, what, genetic predisposition?

[Dr. Peter Attia]

Well, totally different issues. I mean, Anahad, as I write about in the book, had, unbeknownst to him, a very elevated lp, which is genetic. And he was otherwise exceptionally healthy and is to this day exceptionally healthy, but had this genetic issue that was driving, you know, rapidly advancing heart disease. And luckily, you know, was caught really early. I mean, 125 or whatever. His calcium score was pretty darn advanced. But to be able to catch that at such a young age is. Is going to make an enormous difference in course correction. So had he not had that calcium scan done and acted on it, there's virtually no question in my mind he would have died prematurely.

[Tom Bilyeu]

Yeah. So I was going to ask, so if that isn't a driver or isn't being driven by his diet, is it purely just genetic luck of the draw?

[Dr. Peter Attia]

Yes.

[Tom Bilyeu]

Okay, so in the book, you tell a story of somebody that came to you. They had just the worst deck of cards or hand of cards that you could be dealt around. Cognitive decline.

[Dr. Peter Attia]

Well, as in the. They had the worst. I mean, they didn't have the worst, fortunately. They had, you know, a very bad hand dealt to them vis a vis the risk of Alzheimer's disease.

[Tom Bilyeu]

So how do you. If you get a rough deck hand, I don't know, why keep calling deck. You get a rough hand like that, what do you do?

[Dr. Peter Attia]

You start acting as early as possible to mitigate the risk. So we know what one. We have a really good sense of things that people can do to reduce the risk of Alzheimer's disease. And in this particular Woman's case. I call her Stephanie. That's not her real name. We, we undertake a number of things with respect to sleep, stress, nutrition, exercise, supplements that we know are correcting certain deficiencies such as elevated homocysteine levels.

[Tom Bilyeu]

And

[Dr. Peter Attia]

unfortunately in her case, fortunately because she's so young, but unfortunately for many people, we don't have pharmacologic strategies yet. So we're just, I think, on the precipice of sort of some precision medicine ideas. So for example, in our high risk patients who have this gene, the APOE4 gene, we are using a new test called the C2N test that measures plasma amyloid and we're using plasma amyloid as a biomarker for the first time now to track interventions. So in other words, we are using drugs, exercise, nutrition, etc. To try to lower plasma amyloid in high risk.

[Tom Bilyeu]

People talk to me about drugs like this is one thing statins comes up a couple of times in the book. I, I, the only drug I take is an antihistamine and I would stop doing that if I could figure out what it is either in my diet or my environment that's giving me the allergies. But I've had it across like seven different places that I've lived, different states. I mean, it just doesn't seem to matter. I've had wildly varying diets, doesn't seem to impact it anyway. So I take an allergy medication and then I'll sometimes supplement vitamin D. But other than that I, I just have a real hesitation to take any supplementation whatsoever. But you don't seem to have the same fear I have of an isolated compound. So you get people on statins if they have early signs of heart disease?

[Dr. Peter Attia]

Not necessarily. I mean, when it comes to managing apob, which is the thing we're trying to manage on the lipid side, we have a lot of classes of drugs. Statins are one class of drug that's one way to lower APO Hippo B is to use a statin. Statins also happen to have the most side effects of any class of drug that lower lipids. In fact, all the other classes of drugs that lower lipids have no side effects. Statins really have the worst side effects by far. So you might say, well, why do we even tolerate statins? Like, why would we even use them? We use them because we have the most data for them. They are very efficacious, though not the most efficacious. And they may have some other benefits that go beyond their APOB lowering Benefits. So all of that has to kind of be weighed and you have to weigh that against the downside of statins, which are that a non trivial subset of people have at least one of two problems in the presence of a statin. One, they get muscle soreness. The other problem is paradoxically, their glucose metabolism goes to hell. Hmm, not entirely clear why, by the way, but we see dysregulated glucose metabolism in a small subset of patients on statins, and again, we see in a small subset of those patients about 5% muscle soreness. So if we have those symptoms or signs in a person on a statin, and we've chosen a statin as part of the solution in this lipid lowering campaign, we just discontinue it and can it reverses like that.

[Tom Bilyeu]

But when you prescribe somebody a drug, do you do that only when it's like they cannot address this via diet and exercise?

[Dr. Peter Attia]

Yeah, it depends. So it depends on several things. So certain. So exercise has very little bearing on lipids. It has no clinically meaningful benefit on lipids, has a much better clinical benefit on metabolic health and blood pressure, which are also very important in controlling heart disease. So we care a lot about exercise because we want to control those other things that drive heart disease. The big three, by the way, are smoking, high blood pressure and high apob. So again, we're trying to do all of this in concurrent fashion as opposed to just, you know, playing whack a mole on one thing. But nutrition has a relatively minor role outside of extremes at controlling apob. Once a person, once you get a person sort of insulin sensitive, and once you've normalized their triglycerides, unless you're willing to go on profound fat restriction, it's very difficult to get APOB in the levels that we deem appropriate for true prevention.

[Tom Bilyeu]

Would you rather put them on profound

[Dr. Peter Attia]

fat reduction or generally not, because it usually comes at such a high cost.

[Tom Bilyeu]

What's that cost?

[Dr. Peter Attia]

Usually they end up getting insulin resistant because you're now putting them on a very high carbohydrate diet and they're usually protein malnourished.

[Tom Bilyeu]

Why would that be true?

[Dr. Peter Attia]

So it just is a function of what they're eating.

[Tom Bilyeu]

So for two years. So I used to be 60 pounds heavier. To lose the 60 pounds, I basically just ate chicken breast and broccoli. And while not fun, because I was also calorically, calorically restricting so hard. It was fine.

[Dr. Peter Attia]

Yeah. And if that works, that's, that.

[Tom Bilyeu]

Would that be preference though, over a drug?

[Dr. Peter Attia]

Here's What I say no. The answer is no. What I say is diet is a way harder problem to get right than drug. So let's get the diet right first. Let's come up with the diet that works best for your metabolic health, your muscle mass, your. Your sort of fat distribution, and your sanity. Diet is really hard to get right. Maybe not for you. You're kind of a, you know, a highly disciplined person. But for most of us, we want to make sure that we can put you on a diet that you're. You're able to stay with for the long haul. We're not compromising muscle mass. We're not compromising metabolic health. So if that diet also happens to produce very low APOB because it's highly restrictive in fat, fantastic. Stay the course. In my clinical experience taking care of lots of patients, that's not the case for most people. For most people, the diet that produces optimal muscle mass, really good metabolic health and is something that they can tolerate for a long period of time, it's not sufficiently reduced in fat enough to have a meaningful impact on their lipids. And therefore, if we want to get APOB low enough to really get into major prevention territory, we're going to need a drug.

[Tom Bilyeu]

Okay. I'm not sure if it's more enlightening to find out what stack of drugs, supplements you take, or if, based on Horsemen, that is likely to kill you. I have people on these. But I am curious. What. What do you take? Are you on rapamycin, metformin, anything like that?

[Dr. Peter Attia]

I do take rapamycin. I do not take metformin. I do take a lipid lowering drug. I take two lipid lowering drugs. So. One of them is called repatha. It's a PCSK9 inhibitor. So it's an injectable drug that prevents the degradation of LDL receptors on the liver.

[Tom Bilyeu]

That's specific.

[Dr. Peter Attia]

Very specific. So it's a very clean drug, has no side effects, works incredibly well. It's the most potent lipid lowering drug we have.

[Tom Bilyeu]

Did you have a genetic predilection to something that made this necessary?

[Dr. Peter Attia]

I mean, only in that I have a genetic predilection to heart disease. My family history is abysmal for heart disease. So, you know, once that came into focus for me, I was very clear that I was going to do anything and everything to at least take that off the table.

[Tom Bilyeu]

Right.

[Dr. Peter Attia]

And that basically means not smoking, not an issue, having low to normal blood pressure, fortunately not an issue. And having physiologic concentrations of apob, meaning lowering my Apob to the level of a child.

[Tom Bilyeu]

Okay. And you. Are you able to get to that, or is that what this injectable is for?

[Dr. Peter Attia]

I use these drugs to do that.

[Tom Bilyeu]

Got it. Does rapamycin help with that?

[Dr. Peter Attia]

No.

[Tom Bilyeu]

So what's rapamycin about? Explain what it does to people.

[Dr. Peter Attia]

Well, I think that's. That's a bit of a TBD right now. I mean, we, we know what it does in the. On label use. So on label use at rapamycin, which is, you know, taking kind of a medium dose every single day, is an immuno. Is an immunosuppressive dose. And that's how rapamycin was approved in 1999 by the FDA for use in patients with solid organ transplants. So when you have an organ of somebody else put into you, your immune system naturally wants to destroy that organ. So patients who get organ transplants, kidneys or livers or hearts or things like that, they have to be on a cocktail of drugs to suppress their immune system, specifically their T cells, which are the cells that would normally be going after viruses, but now they're going after the organ. So that's nothing to really do with how we're thinking about rapamycin as we're thinking about rapamycin through the lens of what's called zero protection, which means you don't really have a very specific disease you're treating. You're more broadly targeting the process of aging at the cellular level. And there, based on a lot of animal data that's very compelling, it appears that rapamycin does indeed provide zero protection. But it's very unclear as to how to dose it to get that. And how you dose it in a mouse probably isn't how you should dose it in a human, but we don't really know. So if we don't know, why am I doing it?

[Tom Bilyeu]

Yes.

[Dr. Peter Attia]

Yeah, I guess I, I'm. I'm. I'm steeped reasonably well in the literature, and I have a strong enough conviction that the way we're dosing it for this purpose has a much higher probability of being valuable than not. But I'm going to be very quick to abort in the presence of new

[Tom Bilyeu]

information, just as information that you see in the literature in your blood, both

[Dr. Peter Attia]

all of the above. New studies coming out. You know, there's a very important study coming out in three years called the Dog Aging Project, I believe it's called.

[Tom Bilyeu]

Yeah, yeah, Matt.

[Dr. Peter Attia]

Matt Kiberland. Yep.

[Tom Bilyeu]

I had him on the show.

[Dr. Peter Attia]

Yeah.

[Grainger Advertiser]

So.

[Tom Bilyeu]

So very interesting. So if I remember right, from talking to him. Basically, we're trying to get out of MTOR more or less, which is my big fear with my diet, because I eat so much. I mean, so much has changed my mind since reading your book, but I eat so much protein, animal protein specifically. I imagine I'm in MTOR all. All the time. And so it was. Is tempting to try rapamycin, but is that what's really going on?

[Dr. Peter Attia]

Not really. I mean, well, yes, rapamycin is. Is an inhibitor of mtor. That's. That's how the drug works, but it's not. When you eat protein, the activation of MTOR is relatively short. So.

[Tom Bilyeu]

But if you're eating it all the time, wouldn't you then presumably just constantly be stoking that fire?

[Dr. Peter Attia]

Not necessarily. I mean, even if you eat like I do, which is no intermittent fast, still 14 hours a day, I'm eating nothing. Right. So. And again, amino acids do not stick around very long in circulation. So, you know, they're coming on, they're stimulating mtor, and then they're gone. If, If. If mtor, if. If rapamycin's benefit is through MTOR inhibition, specifically, it's probably more through the inhibition of chronic elevation.

[Tom Bilyeu]

Okay.

[Dr. Peter Attia]

And who knows, there may be tissue specificity. It may be more about what it's doing in one part of, you know, in one tissue versus another. Might not be in the muscle. It might be in the liver. There are a lot of unanswered questions here, which is why I think the work Matt is doing is really important.

[Tom Bilyeu]

If you. I'm guessing you have a hypothesis at a minimum, of what the mechanism of action is there that is prolonging life. Like, if we think about. Your whole hypothesis on a centenagenarian is that the four horsemen, they're just delaying longer than anybody else. So what is. Do you guess rapamycin is doing that causes the delay of one or all of those?

[Dr. Peter Attia]

Probably some enhancement of autophagy, probably some inhibition of senescent cells, possibly some reduction of inflammation.

[Tom Bilyeu]

Is it reducing the creation of senescent cells or just the rapidity with which they're cleaned?

[Dr. Peter Attia]

No, it might be inhibiting the secretory factors that they secrete. So senescent cells release these factors that effectively are their agents that poison other cells. And it might be the case that rapamycin is impairing that process.

[Tom Bilyeu]

Very interesting. So that makes me think about cancer. So we talked a little bit about that before. We didn't go into a. So cancer. I don't know if people are more afraid of dementia or cancer. But both of those are pretty terrifying in terms of ways to go out with cancer. We've. I forget how long we've been the war on cancer. We've made precious little progress. Are we barking up the wrong tree? Like, what is it that either makes that so hard? Like, if we know what it is, why is it so hard to deal with? And if we don't know what it is, why do you think that's evaded our eye for so long?

[Dr. Peter Attia]

Well, it's a really good question. You're right that we have made scant process in the most important metric of cancer, which is overall survival. So if you think about it, for everybody who gets cancer, we should be asking the question, how likely is it that they will not die of the cancer that they just got? Another way to think about that is, how likely are they to be alive in 10 years? If you're alive in 10 years after getting cancer, that cancer is unlikely to be the thing that kills you. And by that metric, we've only made about a 5 to 8% improvement in 50 plus years.

[Tom Bilyeu]

Whoa.

[Dr. Peter Attia]

And that improvement has been largely in some very specific cancers. So that's not like across the board, we've gotten a bit better. It's like, no, we got a lot better in a couple of cancers, Namely leukemias and certain lymphomas, A couple of other esoteric cancers like testicular cancer. And aside from that, we haven't really gotten better. Now, very recently, there's some exciting news that does seem more applicable To a slightly broader array of cancers, which is a form of therapy called immunotherapy. So unleashing the immune system to fight some solid organ tumors has also proved to be and some leukemias and lymphomas has proved to be quite promising. But we still haven't figured out a way to unleash that against every cancer, Even though, in theory it should work. Right. Every cancer should have at least some mutations on it that the immune system could recognize as non self. And we know for certain that 80% of them do. In fact, 80% of cancers, solid organ cancers. So these are the ones that are killing the majority of people. Right. So breast cancer, Prostate cancer, Lung cancer, Colon cancer, et cetera. 80% of those cancers have what are called novel neoantigens on them, Meaning they have antigens on them that are novel to the cancer and recognizable by the host's own immune system. The problem is there aren't enough t cells to recognize it to mat to sufficient immune response. So the real challenge of cancer therapy today, in my view, is going to be enhancing that problem, that process. Rather. In other words, I think most of the attention on cancer should be on how do we create more reactive antigens in cancer and how do we enhance and extend the longevity of T cells to attract that. So I'm actually surprisingly more optimistic now about this than I was even when I started writing the book because of what I'm seeing with a class of drugs called checkpoint inhibitors, and also for what I'm seeing with interesting clinical trials where we're seeing the pairing of checkpoint inhibitors, which are immune modulators, and conventional chemotherapy drugs which take tumors that are not previously susceptible to this immune modulation, but then create mutations that then make them susceptible. Really clever and cool stuff. I. I think I write about a couple of examples of that in the cancer chapter. So it's. It's easy to be sort of pessimistic about cancer because of how poorly it has gone for the past 50 years. But I think the next 10 years look a lot better than the last 50.

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[Tom Bilyeu]

Because of things that are already in motion.

[Dr. Peter Attia]

Yeah, because of these processes that are in motion.

[Tom Bilyeu]

So if you got diagnosed with cancer, what would be like step number one? You. What kind of cancer is it? Is it one that responds to immunotherapy? Is there like a protocol that you would walk down?

[Dr. Peter Attia]

No, it would be entirely dependent on what the cancer was. But. And, you know, so that gets to kind of step two of my thinking on cancer, which is the unequivocal, unambiguous understanding that your odds for treating cancer go down the more cancer cells you have in your body.

[Tom Bilyeu]

So detecting it sooner. In the book, you talk about you for your patients, you lower the age of colonoscopy.

[Dr. Peter Attia]

You do everything much more aggressively. So we, you know, we're, we're. We're doing. We're doing colonoscopy much earlier, much more frequently. We're doing.

[Tom Bilyeu]

How often would you do a colonoscopy?

[Dr. Peter Attia]

Oh, it depends on the individual. I mean, in me, I do it every three Years.

[Tom Bilyeu]

Really?

[Dr. Peter Attia]

Yeah. And then I do stool based testing in between.

[Tom Bilyeu]

What do you check for in the stool?

[Dr. Peter Attia]

You're looking for fecal DNA. So you're looking for DNA of the colon. Cancer. Yeah.

[Tom Bilyeu]

Interesting. It has its own DNA. What are we looking for?

[Dr. Peter Attia]

Yeah, you're looking for the DNA that's shedding from a tumor.

[Tom Bilyeu]

Tumors have DNA other than. It's not my own DNA.

[Dr. Peter Attia]

It is your own, but it's mutated. I mean, by definition, every. I mean, cancer is a genetic disease, right? So cancer by definition has mutations that render it different from the host cell

[Tom Bilyeu]

in a way that's predictable.

[Dr. Peter Attia]

Yeah, that's.

[Tom Bilyeu]

We know what breaks in DNA.

[Dr. Peter Attia]

Well, we know. Yeah, we know what's. We. We're sampling what's normal because we see the abundance of that and then we're looking at what's different.

[Tom Bilyeu]

Is there anything abnormal? Very.

[Dr. Peter Attia]

And that's what a liquid biopsy is doing.

[Tom Bilyeu]

How would you do that? Like the sequencing of that? Sounds like a nightmare.

[Dr. Peter Attia]

Not anymore.

[Tom Bilyeu]

I mean, you can sift through that many samples.

[Dr. Peter Attia]

God. Next generation sequencing can do this stuff like it's. It's simple.

[Tom Bilyeu]

How many sequences would you have to do in a single fecal sample to figure out if there's one? Like, is it a thousand? 110, I think.

[Dr. Peter Attia]

Which. Maybe a better question is what's the frequency with, of course, abnormal cells that can be detected in the presence of normal. And that's a good question. I don't know in fecal. I don't know in the fecal test. I know in the blood test, it could be one in a million.

[Tom Bilyeu]

Do you guys. Speaking of feces, do you guys look at the microbiome at all?

[Dr. Peter Attia]

No.

[Tom Bilyeu]

Really? What?

[Dr. Peter Attia]

Don't know what to do with it yet? Nobody knows what to do with it. Anybody who says they know what to do with it is probably trying to sell you a supplement.

[Tom Bilyeu]

That is probably true. Okay, so I'm startled.

[Dr. Peter Attia]

Meaning. Look, there's no doubt that the microbiome is an. Is an important part of human health. Like, we're not. I'm not sitting here denying that or saying the earth is flat. There's no doubt that your diet plays an enormous impact on the microbiome. There's no doubt that, you know, a course of antibiotics will alter. Like all of these things are true, but we're still left with the so what? Question. I've yet to see an example of where someone can show me that I have a person in whom I detect a problem. I check their microbiome. I make an intervention in response to it that I wouldn't have otherwise made, that fixes the problem.

[Tom Bilyeu]

Wow.

[Dr. Peter Attia]

I just don't see those examples.

[Tom Bilyeu]

Okay, so, man, this is very interesting and important to my life. So I think we talked about this before. My wife, seven years ago now, I think, had a. A threshold event where she went from having a manageable gut issue to. I was legitimately afraid she was gonna die. Her hair was falling out, her nails were breaking. She couldn't keep anything down. She was in agony at times on the floor, couldn't be picked up. I mean, it was just really, really brutal. She had to do things like swallow cameras, colonoscopy, endoscopy. Like, I mean, she did fucking everything. And this was long enough ago, seven years, that a lot of doctors only sort of knew what a microbiome was. Like, they didn't know anything about it. They only sort of knew that it existed. And so they couldn't come up with any answers. And it was only through finally getting her tested, realizing she didn't have enough diversity, realizing what we're gonna have to do to start building that diversity back. It was a very long journey of figuring out what the things were that she was responding to. Dietary enzymes, probiotics, prebiotics. I mean, just like this whole arsenal now, it may just be, oh, we didn't actually. And. And to be honest, we don't know which of those things worked. And she's said many because she takes, like 26 supplements a day or something. She's like, I don't know. Do I still need to take them all? She's like, I have no idea. So she just keeps doing what she's

[Dr. Peter Attia]

doing, and we don't know the counterfactual in these situations. And. And I guess what I'm.

[Tom Bilyeu]

What do you mean by that?

[Dr. Peter Attia]

We don't know what would have happened if you did something different.

[Tom Bilyeu]

Yes, very true.

[Dr. Peter Attia]

So that this is. The problem with this space is we don't have clinical trials upon which to extract knowledgeable or reliable information.

[Tom Bilyeu]

Why?

[Dr. Peter Attia]

I don't know. Probably because there isn't enough financial incentive for the industries that typically want to do this. Right. Like, if you're an unregulated industry, which is the supplement industry, what incentive do you have to do a clinical trial? You don't require it to sell your product. All you need is marketing. So that's why no supplement company is out there trying to run a clinical trial. Clinical trials are only run by drug companies because they can't sell their product without a gold standard of a clinical trial. So for as much as people want to kind of poo poo drugs and rah, rah, rah, yay supplements, they should really be thinking about this in the other way. The burden of proof is much higher on a supplement in the sense that we have no clue if it works, let alone if it's not harmful. At least the fda, for all of its faults, and you won't find many people that are more critical of the FDA than I am. I think it's on the verge of being a corrupt organization. At least it tries to hold drug companies to some level of efficacy and safety. It doesn't always do it, but at least it's trying. At least they're going through those motions. No one's even trying to do that with supplements. I mean, the supplement industry is such a filthy, disgusting industry that even though I take supplements, I stress more about sourcing those than I would ever stress about sourcing pharma.

[Tom Bilyeu]

Okay.

[Dr. Peter Attia]

So in other words, you've got to be really careful where you're getting your supplements. So if I'm using a probiotic, which I do during allergy season.

[Tom Bilyeu]

Interesting. A probiotic? Why?

[Dr. Peter Attia]

You know, I. I live in a part of the world where there are really wicked allergies and I don't want to get them. So I've talked to a few allergists and I've said, look, what can I do prophylactically during this season in Austin where cedar fever is out of control? And they say, well, we don't recommend doing immunotherapy until you actually develop the allergy, blah, blah, blah, blah. But. But a couple of them have said, look, we recommend this probiotic. We think it might slightly enhance, you know, this element of your immune response. And I'm kind of like, okay, if there's a 5% chance it works and it's not going to hurt me, I'll take the chance because the only thing I'm doing is wasting money. But, like, I don't find that to be a very. I mean, I do it somewhat reluctantly. Right.

[Tom Bilyeu]

That's so interesting to me that the microbiome would play a role in allergies. I mean, I get it because so much of the immune system's there, but it's just. It's such a unexpected twist, turn of events for me. Even just the discovery that so much my immune system resides in my gut was already startling.

[Dr. Peter Attia]

Yeah. I mean, again, I think the microbiome is interesting, and I really hope we get to the point where we know how to manipulate it.

[Tom Bilyeu]

Do you look at the research on that, or are you waiting for something more stable to come?

[Dr. Peter Attia]

Oh, I intermittently do, but I don't follow that research nearly as closely as what I'm following other things. So it's sort of like every year I'll go back and do a little dive into it with the team and say, okay, is there anything we know today? And, you know, year upon year upon year, we kind of come back to the same conclusion, which is nothing exciting to report yet. I mean, there are edge cases. Right. So fecal transplantation, obviously very efficacious in some people.

[Tom Bilyeu]

Do you worry about fmt?

[Dr. Peter Attia]

I mean, there are huge risks associated with it, as you know. So it's something that should only be done when the risks are justified by the alternative of not doing it.

[Tom Bilyeu]

Yeah. We were maybe a month away from me doing fecal microbial transplant with Lisa because I was just like, this is scary.

[Dr. Peter Attia]

Yeah, understandable.

[Tom Bilyeu]

But for reasons of. It just felt like blood transfusions from, like the 70s or something where it's like I'm scanning for the right things. Very terrifying. So what would you have done if I had come to you with Lisa and said, hey, she's always had gut problems?

[Dr. Peter Attia]

I would have sent you to someone who does that. Again, I'm not saying that.

[Tom Bilyeu]

Who, though? Nobody seems to know. When I say we finally even I couldn't resolve it for her as much as I was learning and meeting with experts. She finally just had to be like, when I eat this, what do I feel? When I eat this, what do I feel?

[Dr. Peter Attia]

Yeah. I mean, again, this is not my area of expertise, so I wouldn't act like it was.

[Tom Bilyeu]

You'd be like, I don't know.

[Dr. Peter Attia]

Yeah, I'm really happy telling people I don't know. There's more things I don't know than I do know.

[Tom Bilyeu]

Yeah, that is. That's something that a lot of people struggle with. I definitely fall into the other camp where I feel like I know just enough to be like, do this. Come back report. So it was really interesting reading your book, seeing how much of the things that I felt like. In fact, I'll say this another way. I have a weird emotional hangup. Like, I really want to. I wanted to say the sentence that I'm going to stop doing intermittent fasting and start doing what you're talking about. And I probably should. Do I have orthorexia? This is a very interesting question. I feel it's so easy for me to maintain my body Composition through intermittent fasting. It's very easy for me to maintain my, my satiety through intermittent fasting. It's when I click over into ketosis, I find that my relationship to hunger is different. But you did say that, that if I'm doing it for body composition reasons. Fair enough. That's very interesting. So one thing that I know, I'm just thinking out loud here, one thing that I do often wonder about with my own physique is protein intake and muscle hardness. When you, like when I'm being really consistent with working out and I take my carbs up, my muscles get really hard. Will I have a similar effect by.

[Dr. Peter Attia]

And you know why that is, right?

[Tom Bilyeu]

The glycogen is being pushed into the muscles.

[Dr. Peter Attia]

It's more water, right? So more carbs means more glycogen. Every molecule of glycogen is bringing three molecules of water. So you're, you're filling up the muscle.

[Tom Bilyeu]

Okay, so then is there none of that relevance with protein? Because I was going to say, like, it's different.

[Dr. Peter Attia]

Right? So, so protein is contributing to the sarcomere, the functional unit of the muscle. The, the. That's, that's, that's the part that's contracting, right? That's the functional piece of the muscle. So that's what's increasing the synthesis of the muscle. And that obviously contributes to size, but it contributes just as much to function. But creatine, you know, will add size to muscle through water retention. Carbohydrates will add glycogen and water to muscle. These things are important for performance also, by the way. So they're not just an aesthetic thing. So carbohydrates, creatine, water, protein synthesis, all of this matters to muscle.

[Tom Bilyeu]

If I were eating more protein, would you expect my muscles to feel more firm? What, am I going to be able to increase my strength more? Like assuming that I hold my workouts the same because I'm trying to think through, do I change my diet or do I just keep doing what I'm doing now? What I'm doing now is easy, but I always thought I was going to depend.

[Dr. Peter Attia]

I don't know how you're working out. So I don't know right now what you're limited by. Are you limited by amino acids or are you limited by progressive overload, or are you limited by some other factor?

[Tom Bilyeu]

So, meaning I'm not overloading the muscle enough?

[Dr. Peter Attia]

Yeah. Are you over. Are you putting enough stress on the muscle or not? Do you have a high enough testosterone or not? Do you have enough amino acid or not, any of those things can be the bottleneck. And are you at the limit of your genes? Right? Like all of these things start to matter now? My guess is virtually nobody is at the limit of their genes except for bodybuilders. So I'm not at the limit of my genes. What am I at the limit of right now? Probably. And I'm not at the limit of protein anymore. I'm probably at the limit of how hard I'm willing to train, how much I'm willing to train. And I'm actually probably at the limit of testosterone as well because my T is pretty low. So I can't answer the question for you. What is more protein going to do? Because I would need a lot more information to understand, like how you're training, what's your training volume, what's your training intensity, and all those factors.

[Tom Bilyeu]

Okay, so one thing, while I have you, that I will say is limitation. When I think about what holds my physique back, I get injured a lot. And I get injured in a very specific, repeatable way, which I think has to do with stability, which you cover in the book. So I have a very weak middle back and I compensate for everything by shrugging my traps. So it almost doesn't matter what I'm doing, brushing my teeth, I will suddenly realize, Jesus. And I have to remind myself to. I think it's retract my scapular. Pulling that sort of mid back girdle down. In the book, you go into how you can rewire the way that your brain has learned to control your musculature. What is that process? I have injured my trap. You're going to think I'm exaggerating. I've injured my trap 115 times over the 20 years. When you say injured, your trap sent it into spasm. So where I can't turn my head or I can't tilt my head, literally last night in bed, I was rolling over, so just adjusting my posture and it went. And I was like, you've got to be fucking kidding. And so then I couldn't fall back asleep because I could just feel it tightening and tightening and tightening and tightening. That is the thing that has, has held me back for forever. It's the first injury I ever received. The first day in the gym doing an overhead press, it went. And I thought I was dying at that point. I was like, what the fuck? Yeah, I've injured it probably at least 115 times.

[Dr. Peter Attia]

Again, it would be impossible for me to kind of give you the diagnostic here. But I think, I think if you think about the way I kind of go through that stability chapter, it starts with respiration. So the first thing we'd have to understand is what's your respiratory strategy? So are you over inflated, under inflated chest breathing only, abdomen breathing only, all of these things. Are you chest out? Are you hunched over? Like you'd want to go through. How do you correct your, your respiration strategy? And then you'd want to look at, do you have, for example, segmental control of your spine? Most people do not.

[Tom Bilyeu]

I can't imagine.

[Dr. Peter Attia]

Yeah. So until you have segmental control of the spine, you are always going to disproportionately put force at various hinge points in the spine. Spine. Do you have thoracic mobility of your spine? Sounds like you don't have thoracic mobility of the spine.

[Tom Bilyeu]

Do you have scap is thoracic mobility?

[Dr. Peter Attia]

So are you able to rotate through the thoracic spine? So you have a cervical spine, thoracic spine is the longest segment and then the lumbar spine. So most people don't have segmental.

[Tom Bilyeu]

Like people that like twist themselves on a chair, that kind of thing. Like, how would you do that?

[Dr. Peter Attia]

Yeah, but if you do twist, where are you twisting through? Where is the torsion? What part of the spine?

[Tom Bilyeu]

For me, almost certainly lower back.

[Dr. Peter Attia]

Exactly. That would be the most common. So most people are excessively applying torsion in the lumbar spine and you want to be able to dissipate it through the whole spine. Also when you talk about the flexion, extension of the spine. And by the way, we made a bunch of videos like, because you can't explain all this stuff in words. So in the book there's a link to like videos where I go through what these things look like. But you know, being able to do a segmental cat cow exercise is a really good way to see if you have, have segmental control of extension and flexion of the spine from head to tail. So, you know, then we get into sort of do you have scapular control through the full range of motion through all four phases. So protraction, retraction, elevation, depression. Again, very few people can, can control their scapula through those things. So stability and movement are, you know, intertwined very intimately. And if you, you know, if you're trying to unpack these injuries, you generally have to go back to the breath training how to train yourself how to breathe properly, training yourself how to move properly. And there are two schools of thought that I have relied on very heavily in my journey here and that of my patients. And that one is called Dynamic Neuromuscular Stabilization DNS. The other is called Postural Restoration Institute.

[Tom Bilyeu]

Priyanka, try bringing everything that I've learned from this conversation and the book today. Tell me if this makes sense. So I would like to add more muscle to my frame.

[Dr. Peter Attia]

Do you know how much muscle mass you have right now?

[Tom Bilyeu]

I don't have.

[Dr. Peter Attia]

You had a DEXA scan?

[Tom Bilyeu]

I haven't, man. I'm really like, I love that stuff. But because no one's coming to my house to do it, I haven't gotten tested. It'd be very interesting.

[Dr. Peter Attia]

You can't do it at your house. You kind of have to go to the machine.

[Tom Bilyeu]

I'm willing to do it. I would be very keen to figure that out. One, I want to see if I have any.

[Dr. Peter Attia]

Well, you should get a baseline, and you should figure out where you are. Where do you stack up right now in terms of muscle mass? If for no other reason, then you can evaluate your progress. Let's say you test your Almi. It's at the 70th percentile. That's great, but do you want it to be at the 80th percentile? Well, this way you can figure out if the changes you're making are going to move you in the right direction or not.

[Tom Bilyeu]

All right, so making my goal maybe even more broad is something you talk about in the book, which is the centenarian decathlon. So what are the things you want to be able to do when you're older? You better be scoring very high on them, depending on what part of your age you're in now, because it's all going to decline as you get older. So here are the things I feel like I should be implementing based on you. I'm 47.

[Dr. Peter Attia]

Okay. And so what do you want to be able to do 40 to 50 years from now?

[Tom Bilyeu]

I want to be able to be very independent from a mobility perspective. So I love the idea of being able to, when I'm flying to Mars, to be able to hold, I guess, before we blast off, be able to put luggage above my head. So, yeah, I want to be able to travel, put things above my head. I don't want to lose a lot of my strength. I want to maintain.

[Dr. Peter Attia]

And if you want to go to Mars, by the way, you're going to have to tolerate pretty high G forces. So think about the neck strength that's going to be required to do that.

[Tom Bilyeu]

Yes. Also, I would just like to not have constant trap injuries. That would be amazing. I want to be able to play video games.

[Dr. Peter Attia]

Okay, tell me. I don't play video games. I do drive a simulator, though, so that's probably similar.

[Tom Bilyeu]

I would guess not from the perspective of what I struggle with. So. I had so much wrist inflammation for so long. I think a lot about inflammation. Inflammation. Keep that down. So thank you, by the way. Your encouraging me to add fat to my diet allowed me to go from basically never being able to play video games to I can now play as much as I want on Saturday, which, I mean, I'm sure I could play more than that, but that's just from a time allocation standpoint, so that's been a huge win. So being able to do that sex, huge thing in my life. So being able to. Whatever that takes. So a certain amount of flexibility, I imagine, stamina, et cetera, et cetera. Yeah. Aesthetics. I want to look good. I want to be strong. Look strong. Something cognitive, like being super sharp. That would be really important.

[Dr. Peter Attia]

Well, I mean, if you're playing video games, presumably, you've got to have pretty decent cognition. Right. You've got to have certain skills and depending on if you want to be doing this.

[Tom Bilyeu]

Yeah. Also true. I don't need to pick up grandchildren. That would be the maybe one deviation from what a lot of people want to be able to do. But being able to be physically active, I mean, take sex is my. Like, I want to be able to do that to the fullest. So given all of those things, here's sort of how I see this now. Breaking out sleep, which we didn't really get into, but obviously I'm going to need to get sleep. That's going to be super important. I'm going to need to identify. Given my family history, I think it's either going to be cancer or heart disease. Neither are sort of overwhelmingly prevalent, but those would be the two where grandparents died of that. So certainly want to be thoughtful about that. So I'd identified those two horsemen. So I'm going to be really thoughtful around my diet, making sure that I don't have fat spilling out, that I'm really thoughtful about. The apo. Little A fuck apob. Apo. That's the one that gets into my cell walls. Arterial walls.

[Dr. Peter Attia]

Yeah. And you do need to check your lp, which is the thing we talked about as well. That is genetic and occurs in. In about 8% to 12% of people.

[Tom Bilyeu]

Okay. So paying attention to my diet, the adjustment that I'm thinking about making, my diet, I'm going to test not doing intermittent fasting. See what that does for my muscle mass. Eating more protein. I have a feeling I might be lower in protein, though. I haven't counted up the eggs. I eat a lot of eggs. And then I'm really curious to see about cycling rapamycin. So what is your cycle on rapamycin?

[Dr. Peter Attia]

I just dose it once a week.

[Tom Bilyeu]

Just take one dose once a week?

[Dr. Peter Attia]

Yep.

[Tom Bilyeu]

Okay, very interesting trying that. What other changes?

[Dr. Peter Attia]

I feel like you're gonna have to have a doctor help you with that. That's not an over the counter.

[Tom Bilyeu]

Yeah, yeah, for sure, for sure. I obviously would be doing this on the back of a lot of blood testing to make sure that I am, A, that I know what my baseline is, B, that I'm actually getting the result that I want to see. So, yeah, looking at the number on the, the cholesterol that we were talking about earlier, grip strength is going to be one again.

[Dr. Peter Attia]

Not, you know, not sitting around with a little, one of those like little grip squeezers. Because that's not really what it's about. It's how do you develop grip strength? You develop it by carrying heavy things. Right. So, you know, this morning I was deadlifting and because I was doing it in the hotel and I didn't have chalk, I was failing in grip today. Like, it's actually funny, my hands and my forearms are still sore five hours later because I was really at the limits of what I could do without chalk. And, you know, I didn't have anything else. So. So, but, so yeah, I was deadlifting. But think about how much I was doing for my upper body, even though that's a lower body activity. You know, doing farmer carries something I love doing. I mean, I'm always trying to figure out a way to, to use my upper body to maximize the relationship between grip and shoulder. So think of it less as like very specific tests that you do and think of it more as the broader activity you need to do to produce that. So grip strength is just an integral of upper body strength.

[Tom Bilyeu]

All right, so if that is my sort of fumbly way through the things, the changes that I'm going to make, if somebody wants to outlive and they come to you at that cocktail party and you just cannot get away from them, and you have to answer the question in a succinct way. What do people need to do to maximize the human life expectancy?

[Dr. Peter Attia]

There is no sentence I can give any person to tell them what their prescription is. Right. I mean, if I could I wouldn't have written a 500 page book. There's no chance, believe me, I didn't want to write a. I wasn't looking for things to do right. The reason this is complicated is that it's complicated and two people can have two very different prescriptions. If I'm at that cocktail party and the person I'm talking to, after a few minutes I figure out that their biggest issue is that they're not sleeping, or that they're sleeping four hours a night, nothing else. I'm not going to really waste time talking about protein with them. We've got to figure out why they're not sleeping seven to nine hours a night. And how much of that is sleep hygiene, how much of that is underlying pathology like sleep apnea or restless leg syndrome, how much of that is alcohol, how much of that you have to get to the root of that problem. But if you're sleeping four hours a night, that's the elephant in the room. If you're not exercising at all and you're sleeping well and you're sort of eating okay, like none of that other stuff matters, you need to get exercise, exercising. If you have type 2 diabetes and metabolic syndrome, you know, we have to get you exercising and changing your diet and all those other things. So, so again, it. I'm not being difficult because I don't want to give glib answers. I, I'm not giving a glib answer because there isn't one.

[Grainger Advertiser]

Very fair.

[Tom Bilyeu]

All right, where can people engage with you to get the non glib details on all of this?

[Dr. Peter Attia]

I think if you go to our website, Peter Attia, and sign up for our free newsletter, you'll very quickly get brought into our world where every Sunday we're gonna spit out something that me and my research team have written on all these topics.

[Tom Bilyeu]

I love it. All right, guys, if you haven't already, be sure to subscribe. And until next time, my friends, be legendary. Take care. Peace.