#04 - AMA #1: alcohol, best lab tests, wearables, finding the right doc, racing, and more

Foreign. Hey everyone. Welcome to the Peter Attia Drive. I'm your host, Peter Attia. The Drive is a result of my hunger for optimizing performance, health, longevity, critical thinking, along with a few other obsessions I've gathered along the way. I've spent the last several years working with some of the most successful, top performing individuals in the world, and this podcast is my attempt to synthesize what I've learned along the way to help you live a higher quality, more fulfilling life. If you enjoy this podcast, you can find more information on today's episode and other topics@peterattiamd.com. Welcome to the inaugural AMA Ask Me Anything not to be confused with Against Medical Advice. After getting a lot of really good questions on Twitter and realizing that I didn't have the bandwidth or wherewithal to respond to all of them, and especially in such a short period of time or short period of space rather, Bob Kaplan, who's my head analyst and I put up a little Ask me anything on Twitter post and over the next week we gathered a bunch of questions. They were amazing questions. We organized them. We got probably over 200. Obviously couldn't address them all in this episode, but we kind of bundled them and I think in many ways we got through probably half of the intended content that people had asked about. So in this episode, Bob interviews me. I didn't really look at the questions before or spend much time preparing, but I also thought it would be more enjoyable that way. And I will say it went by pretty quick. So I guess we were having fun. Depending on how people like this. I think this is a format that we should probably repeat and maybe we'll do this quarterly depending on what the demand is for it. And hopefully we can use this as an opportunity to sort of answer specific questions without necessarily dedicating an entire podcast to some of the topics. So without further delay, welcome to AMA number one, and hopefully it's one of many.

All right.

Hey Bob, Peter, thanks for taking the train down this morning.

Absolutely, my pleasure.

What time did you have to get up today?

I got up at 3am Was that.

Because you had to catch the train that early or is there any other reason you got up a little early?

The train was at 5am So I got a little mini workout in before I got on the train. I wasn't sure if I was going to be able to squeeze one in today.

So we're going to do a double because we'll work out after this.

Very nice.

Are you still doing the squat every day routine? Yes.

Literally squatting every day.

So this morning you just wanted to make sure you had some time for squats.

Just a little bit of time for squats. Yeah, just work up to a daily max and get in, get out, get the Uber, jump on the train.

Well, I think this is officially the first time you're being introduced by voice, at least to people. Though anyone who's been reading Nerd Safari will understand that you are my right hand guy on all things pertaining to blogging and being a nerd. You are the head analyst in our practice and also a very close friend and probably one of the people who's had his foot furthest in my butt to be doing a podcast. So if I'm going to do it, I was going to drag you into it. And I guess this is our first experiment within ama. I think we probably stuck out a tweet like two weeks ago. And how many people ask questions? I feel like there was like three or 400 questions came in.

Yes, definitely over 100 questions.

Well, I haven't been paying attention to them, which is why I cc'd you on the tweet. But I'm guessing you've aggregated them and I have a feeling I'm going to be hearing them.

Yes. So I don't think we'll get to all several hundred questions today, but I did put a bunch of them into buckets so that I'm hoping to cover a lot of ground.

I'm all yours.

So let's start with alcohol.

It's a little early for that, isn't it?

Yeah, well, it's five o' clock somewhere. So this question, I'm just going to read the whole question, but we'll cover the alcohol. I think if there were more characters, I don't know, what is it, 280 characters now? 140. It used to be. So I think this person got all the characters in. Thoughts on consumption of alcohol, Marijuana. Are we sleeping enough? Ever tried cold water therapy and a shout out to Iceman? Hoff. Wim Hof. How can we best enhance brain function? Are we working too hard? Are we too removed from nature?

Oh, Jesus Christ. I can't even remember the first question.

Alcohol. Thoughts on consumption of alcohol, which is a little generic.

Okay, so I put this into a couple of categories. The first is just a purely physiologic. What is the effect of the molecule ethanol on the body? And just as I sort of talk about sugar or other things, it's really important to understand that ethanol is a toxin. But of course the dose makes the poison. Now, the thing that I think many people forget who are not in the world of toxicology, is that there is a probability distribution that drives the impact of a toxin on a population. And there are going to be some people at one end of the spectrum who are largely unimpacted by certain toxins, and there are going to be others who are not. And so ethanol is no exception to that. Just as, you know, Tylenol or pick your favorite poison, could be. So again, Tylenol, meaning, like, even though it's at low doses, very efficacious as an analgesic, at high enough doses, it's hepatotoxic. So start with position one. I'm not convinced that there is a single benefit to ethanol, the molecule in the human body. So ethanol in its metabolic pathway, and it's uniquely metabolized by the liver. One of the byproducts is something called aldehyde, which is a toxin. It really has two, and this is a bit of an oversimplification, but it has two effects. There's an effect on the liver and then there's effect on the brain. The effect on the brain is what people drink alcohol for. It's the buzz, it's the CNS depression that also comes with some euphoria. So it's a bit of a paradox there because ethanol, its effect in the CNS is that of a GABA agonist. And gaba, of course, being is a non excitatory or depressing neurotransmitter. But I think, as most people will understand, certainly ethanol can have an excitatory effect. So you've got this brain effect of alcohol, you've got this liver effect. The liver effect is very similar to that of sugar or fructose. They have very similar metabolic pathways, not identical, but also not surprising that they overlap, given that fructose is fermented to make ethanol. So from that standpoint, no benefit to ethanol. But again, different people tolerate it through different amounts. As a general rule, each beverage, and I'm not talking the kind you pour yourself where they're a little longer, a little taller, but you know, like an ounce of distilled spirits is about 15 grams of ethanol. An appropriate, you know, maybe four ounce glass of wine is also about 15 grams of ethanol, as is a beer, you know, kind of like 10 ounces, 12 ounces, again, depending on the alcohol content. So as a general rule of thumb, each drink is about 15 grams of ethanol. One of the things, if a patient asked me this question, that I'm thinking is, well, what's your liver function right now? And the best proxy we have for that is the alt, one of the transaminases. And, you know, so when I see a patient that's walking around with an ALT that's already at the upper limit of what we consider normal by range today, which I do not consider normal, which is probably 42 on our lab, I consider below 20 normal. I'm always asking the question, do they have fatty liver right now? And if they do, is it more in response to ethanol or is it more in response to fructose? That said, I have at least two patients that I've taken care of either in the past or currently who consume seemingly unbelievable quantities of ethanol. Some of them averaging between 8 and 12 drinks a day. And by ultrasound, their livers are normal. By lfts, their livers are normal. Looking at coag studies, every other marker you can look at, their liver function is perfect. And these guys are sort of the genetic outliers who have a remarkable tolerance to alcohol. So the point I'm trying to make here is I want to get a sense of how much harm is coming, purely in a hepatic sense from alcohol, and then make sure we're drawing a line well below that. But the second point is perhaps the bigger point, which is the why? The why are we drinking alcohol? And I say this as a guy who likes alcohol just as much as the next person, but certainly in my life, I've started to ask, am I drinking just for the sake of drinking? Am I drinking because I'm trying to soothe some other issue? And does my drinking lead to a behavior that I'm otherwise not happy about? And in my case personally, that generally tends to loosening the reins on what I eat. And I don't think I'm unique in that. I've got many patients that when confronted will say the same thing, which is, yeah, ultimately that's the problem with ethanol is you go out, you get a couple of drinks and things that you otherwise wouldn't eat, you just start eating. So not that this is at all scientific, but my rule of thumb is the following. As a general rule, I don't want to drink. If I'm going to drink, it's going to be good alcohol. I'm going to make it purpose driven drinking. So I don't drink on airplanes because the alcohol sucks. Like, I'm not gonna. Just because they're pouring me some half assed glass of wine, I'm not gonna drink it. But if I Want to drink wine? I'm gonna drink wine that is exceptional. If I'm gonna drink tequila, I'm gonna drink tequila that is exceptional. And if I'm gonna drink beer, it's going to be exceptional. And because somebody's going to ask what are my favorites? My favorite wine is Clio, which is a Spanish blend and I've been drinking it since 2007 and I've had every bottle from 07 to 14. And I'm fully expecting that people listening to this are not going to go and start buying Clio like crazy because sometimes it's hard to find that I'm going to be really pissed off if I can't get it. Tequila. I know Everybody raves about 1942 and I think it's good, but the Classe Azul Reposado is absolutely my favorite. It must be consumed neat, no ice, no lime, no nothing. And my favorite beer, I'm not willing to say what it is because it is so hard to find. And honestly, not to be a selfish prick, but I'm simply not willing to share it with anybody. One of the guys who works for me's part time job is sourcing it across the United States and Belgium. So I'm sorry guys, I'm not gonna let on what that is. So that's my thoughts on alcohol.

Okay, Any. Can I make a follow up question, please? Okay, so more or less you said there's nothing beneficial I'm sure you're gonna get, but what about the French paradox? What about red wine? Isn't a glass of red wine maybe two for men? Maybe three, maybe six, depending on who you ask. Isn't that associated with better health or less cardiovascular disease or more longevity?

Yeah, I mean, I think the red wine thing came about through two things that you mentioned. One is the French paradox, which is, boy, the French seem to live a lot longer and they drink more. Ergo, it's got to be that. Of course, I think that to get into that topic in detail would sort of take the rest of our ama and it really has to do with just a poor understanding of epidemiology. So there are a lot of things that explain the French paradox. They also smoke more. I don't think that that necessarily means smoking is better. So it probably has a little bit more to do with what they eat than what they drink or don't drink. The other thing that I think has a lot of people with this lingering idea that, you know, a glass of red wine a day must be healthy. And I want to Be clear. I'm not saying a glass of red wine a day is harmful, but I'm saying it's, it's not benefiting your health is the resveratrol story. So resveratrol is a compound that is identified in very small quantities in red wine. And there was one lab in particular at Harvard that many years ago, when I say many years ago, like probably 15 years ago, maybe 10 years ago, David Sinclair's lab had studied this in high concentrations and they showed that it enhanced longevity and that created like this huge wave of everybody wanting to take resveratrol supplements. There are two issues with this. The first is, even if you believe those data, which I categorically do not, and no lab has ever been able to reproduce them, and I'm not even convinced that Sinclair today would believe that those were valid, you would not get that amount of resveratrol in a glass of red wine. So it's sort of like the, should I be eating more dark chocolate to live longer? Maybe. But you're probably better off just taking cocoa flavonoids. If you buy that, that's the active ingredient that's going to enhance nitric oxide production. The one thing, I guess I'm glad you asked this follow up question because I have some patients who will argue this and honestly, maybe they're right, which is there are some patients who say, look, just a single glass of wine a day helps me unwind a little bit. And isn't there any benefit in that? And I guess the answer is possibly. And so the question is, does the net benefit of that, which could be a lower amount of cortisol, a lower amount of emotional distress? Could those things be beneficial relative to any of the potential drawbacks of ethanol, such as, you know, increased, you know, appetite dysregulation, or I'm not even getting into sort of pathologic behaviors, maybe one thing I have observed in the oura ring has made it very easy for me to track. This is one drink in the evening does not impact my sleep. Two or more absolutely does and does so in a profound way. The two things that happen are my resting heart rate will be 10 beats higher. It will take very long for me to reach my resting heart rate. So what you want is your resting heart rate to be achieved within the first third of your sleep cycle. And more importantly, and perhaps more surprising to me is my heart rate variability gets squashed. So I have a very low average heart rate variability when I have more than two drinks. And even the volatility of my variability is very low, and that is reflected in my sleep. It also definitely compresses REM cycles. So even though when you have a few drinks, you're groggy and you think you're sleeping better, you're just less conscious, but you're actually sleeping worse.

Okay, let's move to the next one. Best lab tests is the bucket that I put this one under. So there are a couple of questions. At least one question was, what four to five tests? Can we go to our pcp, our primary care physician, and request they run? Second question. What are the best lab tests as markers for longevity?

Well, so the first one is, and I guess you could divide these into things that you really only need to have checked once, and then things that maybe you ought to be checking more than once. So a couple things that everybody needs to have checked once is LP and apoe. So LP is a phenotype, but it effectively reflects a genotype, the LPA gene. And we're going to have an entire, probably two and a half hour discussion on lp. So I'm not going to say anything more about that. But suffice it to say, if you're listening to this and you don't know why, I'm suggesting that you will. But everybody needs to know their lp, preferably their LP particle number. But LP mass is, to a first order, a reasonable approximation. Apoe, of course, is a gene, and it exists mostly in three forms, the 2, the 3 and the 4. There are others, but they're almost. I've never seen one. And because it's a gene, you get one from each parent. So therefore you can combine the 2, the 3, the 4, into six combinations. 2, 2, 2, 3, 2, 4, 3, 3, 3, 4 and 4. 4. And it is important to know those, in my opinion, though I will certainly find myself arguing this point with physicians who say, why the hell would you ever want a patient to know that there's nothing you can do about it? Because, of course, this gene is probably the second strongest gene to predict Alzheimer's disease by magnitude, but the strongest by far by frequency. In other words, it's the one that matters more at the population level. I would agree with the logic of said physicians if I felt that there was nothing one could do to impact their chances of Alzheimer's disease. Obviously, I think that that's sort of nonsense. You and I and Dan co authored a paper with Richard Isaacson at Cornell and a few of his colleagues on Alzheimer's prevention. So we're obviously in the camp that thinks Alzheimer's disease is at least somewhat, if not significantly preventable, and therefore genotyping gives us great insight. Furthermore, APOE genotype gives enormous insight into cardiovascular risk, something that we probably ought to do a dedicated discussion around apob, apoc and apoe, just straight up APO talk. I'd like to talk more about that now, but it's probably irrelevant. So you got to know your lp, you got to know your apoe. The other thing that, again, I sort of think a lot about is if LP is the single most important lipoprotein, then LDLP or APOB would be the next most important. So that's also something that I really think ought to be tracked. Boy, we're only allowed five, huh? Because I really. I guess I take for granted that we can just order lots of lab tests.

Can you explain. Sorry to back up when you say LDLP or apob. I think some people might think like, you can get either or test, but they're more or less testing for the same thing. Can you explain how APOB relates to the LDL?

So there's actually two APOBs. There's APOB48, which is an apolipoprotein that sits on something called a chylomicron, and then there's an APOB 100, and there is one and only one APOB on each of the following molecules. VLDL, IDL, LDL, and also LP. So by counting the number of APOBs, you are counting the number of LDL particles. But because you measure APOB in mass, it's measured as milligrams per deciliter of APOB versus LDLP is measured in number or nanomole per liter. So the number will look very different if I said, tell me. Your APOB and your ldlp, they will have different units and therefore not look anything alike, but they're proxies for the same thing. And that, of course, changes. It's influenced by four things. It's influenced by the amount of cholesterol you synthesize, the amount of cholesterol or sterol that you reabsorb, the amount of triglycerides you have to carry around, and your clearance of the particles, which is primarily driven by something called the LDL receptor or LDLR that sits on the liver, and because those four factors can all change in response to diet and drugs to different extents, obviously triglyceride is by far the most sensitive to nutritional change, LDL receptor, probably the most genetically preset. But there are ways to tweak these things. And certainly drugs tweak them. So we've got lots of ways to do that. But this is an important thing to know. I mean, the four lipoproteins that approximately this order are important is Lp, LDLp, small LDLp, the subset of LDL that are below some cutoff, typically about 20 nanometers. And then we don't have a way to measure something called the VLDL remnant. So we use the poor man's proxy. As I look at VLDL cholesterol, which you take the non HDL cholesterol and subtract the LDL cholesterol, which you get off a standard lipid panel, that's especially helpful if at least the LDL is measured directly. But then of course, you're often compromising and getting an indirect measure of the non hdl. So. But that probably is a better proxy than taking triglyceride and dividing by five, which is the other poor man's way to get a VLDLC. And I like to see that number less than 15 milligrams per deciliter.

Did you just find a utility for total cholesterol test?

I have zero utility for total cholesterol. I think the only time a clinician should ever even pay attention to that number is if you have a patient that you are concerned has FH familial hypercholesterolemia and you're trying to get them approved for a PCSK9 inhibitor, then you will actually need to know their total cholesterol and their LDL cholesterol, because you will use cutoffs typically total cholesterol More than 350, LDL cholesterol More than 250 milligrams per deciliter as your cutoff. But I don't pay attention to LDL cholesterol, I don't pay attention to total cholesterol, and I pay minimal attention to HDL cholesterol. I'm more interested in the ratio of triglyceride to HDL cholesterol. But as we know now, increasing HDL cholesterol pharmacologically does not seem to have any benefit. I'm not even convinced increasing it dietarily does. I think it just goes along for the ride. In other words, I think that the things in a person's nutrition that increase their HDL are benefiting, but not because of the hdl. The HDL C is going up as a result of it. So I guess after all that rambling, I've basically said three things, which is lp, apoe, ldlp. I think Everybody should encounter an oral glucose tolerance test, and in particular one that uses insulin as well as glucose. So not uses insulin, but measures insulin. So you would take a fasting glucose insulin level, you would take consume a standardized amount of glucose. Typically, it's recommended to use 75 or 100 grams of liquid glucose called Glucola. We do that for most of our patients. However, I am now on occasion using normal glucose to challenge them. So 100 grams of glucose in the form of rice or potatoes. Because I do think there's a subset of people who you're getting misleading responses from when you're using liquid glucose, which is actually quite unnatural.

You don't consume Glucola regularly. I mean, I, I didn't look in.

Your fridge, but you know, I've got six bottles back there. But I save that only for the special occasions, like along with the other alcohols that I like. No, the shit is horrible. Taking enough of those glucose tolerance tests, in fact, I'll probably never do one again. I'll probably from now on only do them with, you know, rice or potatoes or something like that.

Is that complicated to do the OGTT with insulin or is that something that most.

Well, you know, it's interesting because I do see some stuff on Twitter about, hey, why do I need to go to my doctor to do that? I can just do it at home. And you can do it at home with the glucose response because, you know, we have portable glucometers, but insulin can't be measured easily. It's not a test you can do at home. So it needs a laboratory. And if you're not seeing the insulin, you're not knowing the answer. So if you fail a glucose tolerance test on glucose levels, well, then you've really failed. And what do I define as a failure? I want to see fasting glucose typically below 90. I want to see 1 hour post prandial below 120 to 130, depending on the amount of muscle mass the person has. And I want to see 2 hour glucose below 100. In other words, I have much more rigorous standards than the laboratory form would show. And you can be there and still have hyperinsulinemia, especially postprandially. Usually a person there will not have hyperinsulinemia when fasting, but it's not uncommon. In fact, I'm seeing a patient tomorrow. I was just looking over his labs today and he's great. Fasting glucose. Fasting insulin is below 6, which is my target. At one hour, his glucose is like 114. Great. But his insulin is 56, and at two hours he's fine below 100 and his insulin's below 20. So what is the implication there of this guy who's got basically only one X on his record, which is his one hour insulin is 56? Well, that's, as Joseph Kraft describes, that that's diabetes in situ. So that is postprandial hyperinsulinemia, which is a harbinger to insulin resistance. And look, he might be five years away from being insulin resistant, but that's exactly the time I'd like to be able to intervene. And so this is one of those tests where, yeah, it would be a lot easier if we could just do it at home with our glucometers, but I think it is worth the hassle of doing it and getting the actual insulin data. Boy, what else do I like to see? I've already got pretty heavy focus on the cardiovascular, so I'll try to avoid any other cardiovascular stuff. Although obviously a C reactive protein, a homocysteine, or an oxidized ldl, or an oxidized phospholipid are really, really helpful. But I think since we're only going for five, probably alt, which I alluded to earlier, I think today we're just seeing so much fatty liver disease. And again, the labs, which are basically showing you plus or minus two standard deviations have just seen an upward drift of this over decades. And I was actually just talking about this with Rob Lustig a while ago on another podcast, which I don't know what order we're going to release these things, but that'll either have already come out or be coming out. But we were talking about how we both sort of share this point of view, which is we just kind of ignore the laboratory references on many of these things. And for ALT on our Lab, up to 42 is normal. If I see a patient walking around at 38, I'm highly alarmed.

You made a great point about that, too. I snuck in a listen to that podcast.

Sneaking in listens on the podcast already.

Membership has its benefits, the alt. So 42, I think you said that's considered normal today, but 30, 40, 50 years ago, that was not considered normal.

That's right. Why? I mean, I think Rob would argue, and I would agree, that as we've seen an increase in fructose consumption, it's driving a greater and greater prevalence of NAFLD. This was a condition that wasn't even recognized 20 years ago. If the last data I looked at are any indication, by 20, 25, the combination of the success we've had treating Hep C and the rampant rise in NAFLD means by 2025, this will be the Nash, which is the sort of Nash, NAFLD to Nash to cirrhosis. That pathway will be the leading indication for liver transplant in the United States, which is sort of hard to contemplate when you realize that in the year 2000, less than 1% of liver transplants were for non alcoholic fatty liver disease.

And I think one of the things about the lab, the reference ranges is that they're based on the population mean. So 30 to 40 years ago, an alt, a normal alt, would be actually considered lower than 42. But because the national average is higher, when you look at a lab test, you're within range. You may be at 42 and you're looking at it and saying, I want it below 20.

The other thing I've seen enormous drift on, even just in my very, very brief career on a relative basis, is estradiol levels in men. I mean, I've seen two upward shifts in the range at the same lab over eight years. So men are becoming more and more and more estrogenized, and there are lots of reasons for that, which we'll probably talk about on another podcast. So those are my. I can't even remember. I lost track how many labs I recommended. But I think the spirit of the question was if you, if you're going to be a minimalist, what are you going to do?

You got five in there, definitely. Does that cover just in general, or does that also cover the markers for longevity? Do you want to get into, like, if you could actually measure some things for longevity, but you really can't in a lab test that you would want to look at.

So if we're talking longevity purely in terms of lifespan, how long, you know, looking at someone's blood, can you get a sense of how long until they're going to die? The way to think about that, so what you're not going to get on a standard blood test is any of the longevity genes. I mean, you can get some of them, but certainly APOE would be one of the longevity genes. LP would be a longevity gene in inverse. So the lower your lp, the greater your chance of cardiovascular mortality. So the way I really think about longevity in blood is the three things that you're looking for in blood, disease wise, are what is this person's risk of atherosclerotic disease? So heart disease or stroke, what is this person's risk of cancer? What is this person's risk of neurodegenerative disease. So as you march down those things, you would say, well, cardiovascular disease largely driven by three things. Lipoproteins, inflammation, endothelial dysfunction. How much of that can we see in blood? Actually, a lot. On the lipoprotein side, we can see most of what we want, which is the lp, the ldl, the small ldl. I'm talking particle number, not cholesterol, and the vldl, as alluded to. On the inflammation side, we can see specific and nonspecific markers of inflammation. So on the non specific side, we can see things like fibrinogen C, reactive protein, protein. On the specific side you can see things like OXLDL, LPPLA2, OX, phospholipid. Those things, very helpful. Endothelial health is the hardest thing to see, but I include insulin here because I think that insulin is in and of itself actually toxic at high levels to the endothelium. And James o' Keefe just recently was on a paper that looked at cardiovascular health in patients with type 1 diabetes. So that they were able to actually use the insulin doses that people were using as a way to actually assess the impact on the. I can't remember if it was myocardium or endothelium. You can look at things like homocysteine. We also look at something called asymmetric dimethylarginine or ADMA and sdma, which are inhibitors of nitric oxide synthase. So the way I tell patients is the younger you are, the more your blood tells me about your risk of cardiovascular disease. So a 40 year old person who otherwise doesn't have like some dramatic, you know, LP through the roof or something crazy. The blood tells me probably 80, 85 of what I need to know. The older a patient gets, the more I would probably rely on things like CT angiograms or even usually by the time they're older, a calcium score becomes less relevant. Calcium score can be somewhat helpful in a younger patient though. But the latest study I saw, which actually just was an editorial that came out two days ago based on a study in one of the atherosclerosis journals, was looking at 50% of patients that had events had them at the site of non calcified lesions. Not a huge vote of confidence for how, why a low calcium score is that helpful on the cancer side. I think that's really, frankly where blood gives us the least insight. You know, until companies like Grail have fully functioning liquid biopsies where you're Looking at, I think Grail's probably looking mostly at RNA and DNA. Other companies have looked at circulating proteins, but until these liquid biopsies are there, we don't really have much insight into it. Also, virtually every cancer is a result of a somatic mutation, not a germline mutation. So knowing your genotype doesn't really help outside of a few outlier things like BRCA or Lynch. So in cancer it really comes down to understanding inflammation, which we've already addressed, and metabolic health, which again was also part of the cardiovascular stuff, though I didn't go into it. But so for me, minimizing hyperinsulinemia becomes very important. And I suspect we'll probably have an entire discussion on the role of IGF in cancer and IGF BP3, because I think it's actually quite controversial, but that can also provide some insight. And then Alzheimer's disease actually I think is more closely related to cardiovascular disease in terms of risk stratification. So first of all, knowing the patient's APOE immediately gives me a bucket to put them in, which is low, medium, high risk. I mean, that's, I don't call it that, but that's sort of how you can think about it. And then you look at the other dimensions of it, which is there's a vascular component to that disease and that basically proxies what you're seeing in cardiovascular risk. So the more you can improve the cardio metabolic profile, the more you can improve that. Then there's the metabolic component period, which is kind of like the glucose utilization part, and that sort of reverts back into all the metabolic stuff you see in cancer. There's an entire thing around toxins, which unfortunately is probably the one that we have the least insight into measuring. And for very high risk patients, we do refer them to Richard Isaacson's clinic at Cornell, which is a dedicated high risk clinic. And certainly there, if the cognitive test warrants it, they'll do lumbar punctures and start to look at CSF for other markers. But obviously we don't do that and unfortunately we don't have too many patients that are crossmojinating over there.

I don't want to harp on this one, but I thought it was a good point that you brought up you touched upon with the insulin and that some people will get a, they'll get their glucose tested every year and they say, my glucose is fine, it's 82 or whatever it is. And if they assume that their insulin's fine too, because they're Clearing their blood sugar and it's 82. Can you explain just why you're not. I mean, you're literally not looking at insulin. But insulin could be elevated and you wouldn't know it.

Yeah, correct. Yeah. And usually the person walking around with a fasting glucose of 82 probably doesn't have a very high fasting insulin. It's the postprandial stuff you worry about. And then this gets more complicated because you then have to worry about are you being misled by the test? So I'm sure many people are listening to this who are already aware of this, but I'm sure enough people aren't that it's worth the time. But if you take somebody who's on a ketogenic diet or a very carbohydrate restricted diet, it's more common than not when you do an oral glucose tolerance test on them, that they will have this paroxysmal, very elevated glucose, very elevated insulin after being challenged. So they'll have a low fasting glucose, low fasting insulin, and then you give them the glucola and their glucose and insulin are sky high. I think I may have told the story once on a podcast about a guy I knew who had gone on a low carb diet and everything had gone great and blah, blah, blah, he lost a bunch of weight and got healthier and everything was amazing. And then his brother, who had type 1 diabetes, needed a kidney transplant and he was a match. So they said, well, all right, we just gotta test you, make sure you're not diabetic or anything before we take one of your kidneys. They didn't ogtt and he quote, unquote failed. And he called me in distress and he was like, oh my God, I can't even give my brother a kidney. And I said, well, here's the thing. You got to have them repeat the test and just you got to refeed with 150 grams of carbohydrates. Just eat 150 grams of rice, potatoes, whatever. For about three days leading up to the test, they repeated the test. Obviously everything was fine. The next time he called me, he was leaving the hospital after the transplant, everything had gone well. The other thing with fasting glucose, by the way, that's kind of useless is it's helpful if your fasting glucose is 150. There's clearly a problem. But I get patients that get, you know, very upset or phosphorylated if their fasting glucose is 105. And I gotta tell you now that I Wear a continuous glucose monitor. And I know my glucose 24 7. The difference between a fasting glucose of 90 and 105 in the morning is much more a function of my cortisol level than it is anything to do with my insulin sensitivity or, you know, any, anything like that. So it's, you know, it's important to understand the role that even stress can play on glucose. And that's why I think fasting glucose is directionally interesting. But it's the, it's the insulin that gives you the more fine tuned insight.

Okay, this might be jumping around a little bit, but you talked about your continuous glucose monitor and I think a couple people asked about that because they realized that you have a CGM and you're not diabetic. Because usually when you have a CGM people say aren't you diabetic? Because it's what it's typically used for. So we could get into a why do you wear the cgm? And then probably a pretty nerdy game of would you rather, which is obviously not the glucose, but let's say like an OGTT with insulin. Would you rather see that in a patient or if a patient could have the, you know, the Dexcom 5 or whatever the latest and greatest is and you knew exactly what they ate for like a month and you could follow those numbers. Are you going to learn more about that patient through one of those tests or the other?

Boy, that's a good question. I think that to have CGM data on a patient and a lot of our patients don't want to wear a cgm, although I think that's going to change with the Dexcom G6. So I started my career using the G5. Now the G5 I loved. But I could understand why if you didn't actually have diabetes, that was a bit of a stretch because you're inserting this needle and it was just a bit more involved. Plus it required calibration twice a day. Then a company called Libre got bought by Abbott and they had a no calibration, one that got quite popular, but we've used it a lot and I find it to be categorically useless. It's so inaccurate and you can't force a calibration. Also it doesn't have, you can't, it doesn't interact with your phone. So it's just like useless in that regard.

So do those both use a needle in the same place?

The Libre is typically inserted on the back of the arm and it was at the time a much easier way to insert the new Dexcom G6, which I don't think is out yet, but I've been lucky enough to have a prototype for a while. The G6 inserts the same way as the Libre. It's plug and play. It's trivial. You don't even feel it going in. It's a much smaller needle, goes in much faster. So you don't, you're not, you're not the one responsible for the velocity at which it goes into you. And it also doesn't require calibration, though you can. I still spot check mine once a day. I've been blown away by the accuracy and its interface with the phone is second to none. So it's just, it's just, it's amazing. I think in reality, if I had a month of CGM data with accurate food information, that's probably more valuable to me than the ogtt. Even though I'm giving up insulin, meaning I'm not going to get to see the insulin, but I also get to see, you know, a month of someone in their real environment eating the likelihood that I'll miss in that entire month because they're going to probably eat something really bad. And if I can see how they're reacting to that, you know, that's probably pretty good. But look, it's still not a complete substitute for that hyperinsulinemia. So it's, it's a, it's, it's not perfect. But I also find that the CGM for me is one of the. It's, along with my sleep ring, it's the stickiest device I've ever used, whereas any other wearable I've ever used, it's like after two weeks, I don't want to wear it anymore because I've already learned what I need to learn. Like, I know how many steps I take. Why do I care? So I've got this whole theory around what wearables matter. You know, it's like, are you measuring something that matters? I don't want a wearable that's telling me something that's irrelevant clinically. Is the device actually measuring what it claims to be measuring? Am I able to get feedback in real time? Because that was the problem with the Libre is you couldn't get real time feedback, you know, unless you were going to carry around this other device it came with. Whereas with the Dexcom, you're getting real time feedback. And so as real time as exists, meaning when you eat something, you don't see your glucose move at that moment. But I certainly know after a Meal, how that meal or the amount of exercise or the amount of stress I was under impacted things. And then do I have an ability to sort of fix it? Do I have any control over the outcome? So, you know, CGM for me has continues to this day, even though we're probably three years into doing this stuff. I mean, it's hard for me to imagine a day when I'm not going to want to know my glucose every minute of every day.

How much of those two things, particularly the cgm, maybe the ring too, because you're talking about a lot of things, probably sleep, exercise, diet, et cetera. Are these things almost like accountability coaches, that the idea that you get this real time feedback of the stuff that you're eating, if you're going to eat some crap, whatever it is, you know that it's going to show up. Do you think that there's any of that aspect to those things?

For me, there definitely is, especially on the glucose ring. I had a buddy stay here last night and like, after we went out and grabbed dinner, and then on the way home, he's like, oh, do you mind if we stop at the store? I want to get some stuff for the morning. And he, you know, got a little box of granola. And so, you know, this morning, you know, get up to our thing and he eats some of the granola, but left the box. And as he left, I'm like, God damn it. Like, I love granola, but, like, it's candy, it's not. It's nice. Like, you know, so I just threw it out immediately. Like, open the thing, threw the granola out and make sure I wouldn't eat it. And in part, I think it's that I know that if I eat it, I have to look at my cgm, just go up and it just pisses me off. So it's like, I'm not going to do it. And maybe if I didn't have that cgm, I would have mainlined that whole box of granola.

There's a question in here that I have to get to because it might relate to this. It says, how do you think having children has changed you most? I often think of what's at the dinner table and what's left over in terms of your, if you want to call it willpower or food that's left over that might come into play.

I mean, I hate to blame my kids for anything, but I'm easily 10 pounds heavier and 10 pounds fatter thanks to them. I think the biggest issue is the food environment. You know, here in New York, I eat really well because. You mean, you see my kitchen. The worst thing I'm gonna do. Yeah, yeah. The worst thing I'm gonna do is have a little extra almonds tonight. Like, there's just nothing bad to eat in here. And this is where I'm at my weakest, is when I'm in my place. And it's not to say I don't go out and eat a burger and fries sometimes, because certainly New York offers more of amazing, decadent food than any place else. But I think we're most vulnerable in the environment that we eat most. And for some people, that's work. For some people, it's home, whatever. And so I think that the challenge of having kids, at least for me, is that you just have more kid food around. And try as you might to say, we're not gonna have that kind of stuff in our house. I mean, look, I'm guessing my kids eat better than most kids. You know, they don't have juice in the house, Soda. Like, a couple times a year, there's like, you know, some Diet Coke after a birthday party or something. But, you know, for the most part, it's pretty good. But there's still a bunch of crap, like, you know, those crackers, Wheat Thins. My son, who you know very well, he calls them Wheat Thins. And he freaking loves those things. Like, it's all he wants to eat. And he comes home from dayc, and he's like, daddy, I want some Wheat Thins. And I'm like, what? Wheat Thins. What are you talking about, Reese? Wheat Thins. Oh, Wheat Thins. Got it. So. And I.

We not thin. We not. We not thin.

And those things. I mean, I don't know if you've had one of those in a while.

Yes, I have.

They are freaking awesome. Yeah, they must be. Just. They're so. I don't remember them being that sweet when I was a kid.

The texture, too. Yeah, I remember. Yes. There's a period. I would stack them up, I think, too.

Maybe stack up a couple. Yeah. Oh, yeah, yeah, yeah. You don't eat those things one at a time. I feel like Will Ferrell in what was that hilarious movie? Old School. Old School. It just feels so good when they.

Just hit your lips.

And then the other thing is, there's just, like, a lot of the times if I'm. You know, the kids will want homemade Mac and cheese, which is, like, nowhere near as bad as the crap you get out of a box. But look, it's still Mac and cheese. And if they don't finish it, I still have this immigrant mentality I grew up with, which is like, you don't throw food out, which is horrible. But I was really raised. Like, that was so instilled in me that you don't throw food out. So if my kids don't eat their Mac and cheese, I'm like, yeah, I gotta eat it. And part of that's just I want to eat it, but part of it's like, I really don't want to throw it out. So I'm just as likely to finish off their salmon or steak as I am their Mac and cheese. So I don't know. I mean, I think the benefits of having kids have probably outweighed that, but that's definitely a draw drawback of having kids.

So before we leave, the lab test. This is technically not a lab test, but I've heard you talk about it a lot, and it's something that people probably could do and it might be a good exercise for them. And that is family history. It can tell you a lot about your risk, maybe more so than some markers. Can you talk about the importance of that a little bit?

Yeah, I think it's certainly more important than doing a whole genome sequence. So I've had a number of patients. I mean, at least half my patients over the last few years have either done a whole sequence or at the very least done something like 23andMe. And we run that through Prometheus, and I'm trying to think of a single time when anything in there altered our treatment plan beyond what we already knew. Maybe the odd patient that shows up with a Tom40 mutation who was otherwise an APO33 that you think, okay, you're probably a little higher risk than we thought for Alzheimer's. So maybe that's one exception. You know, we get some insights into caffeine metabolism, but we almost always know the answer before we, you know, we look for it just based on what they tell us clinically. But the family history is incredible. And a lot of the times you can see things in family history, like you can often spot an elevated LP before you get the bloods back. Because usually I've done a history and a physical on a patient before I get their first blood test back. And it's not uncommon for me to see just a violent streak of heart disease in a family and be like, okay, you're gonna have an elevated lp. There's no two ways about it. And sure enough, they come back and it's high and you could see that their dad had it, their dad's mom had it, their dad's mom's mom had it. And you just sort of. Because it's a co dominant inherited gene. So you can see how it rattled through the family. Certainly also gives you a great insight into cancer and dementia as well. I mean, I think dementia's harder because obviously the further you go back, the less long people were living and you don't mentally. But as a general rule, we really look for the mosaic and pattern of a person's predicted mortality based on their genes and things will skew it. Your parents smoked and you don't smoke and they're getting disease all over the place. It's hard to infer there. I have patient whose mom just died very recently from lung cancer, but it was non small cell lung cancer. So what do you do with that? She was a heavy smoker, he's not. Does that really increase his risk? I mean, as you know, we do a staggering amount of work on cancer screening in our patients and you basically are the guy who runs our model on that. And it's actually a cancer by cancer issue. There are some cancers in which a first degree relative that has it. It's a big, you know, and sometimes it's not obvious like the first degree relative that has bladder cancer. And what's the relationship to you having prostate cancer or vice versa? So when we do the cancer screening in particular, we have the patients go back and do an even more detailed double click on their family history of cancer. So yeah, I think family history is probably one of the more important things we get out of the history on the patient.

MD selection. I think you've received this question more than once. How do I find a good doctor? So what is the best way to find a really good primary care physician? Are there specific telltale questions, labs I should bring up with the prospective pcp? I think we covered that, but also to see if they've picked up a medical journal in the last 20 years.

I actually had this discussion with a patient on Monday who's looking for a concierge primary care physician. Since I'm not a pcp, many patients come to me already with a pcp, but sometimes they don't and they want to have this question. So I kind of walked him through my mental model, which is there's no one size fits all here. You just have to decide what it is you need and want. So I think about availability, affability, ability and advocacy as sort of the four broad pillars that you're looking for in a physician. And it's pretty much impossible that you'd find all of those in the same person. So what do I mean by those things? So advocacy is the physician who's connected and knows how to help you navigate through a storm. When you need to go get a colonoscopy, they know the absolute best endoscopist. And if God forbid, like something comes back with a positive finding, they know exactly the right surgeon and boom, boom, boom. And not only do they have the Rolodex, but they know how to help you get through that. They will be your, you know, your advocate in the system. I personally think that's very important. I think many people aren't actually thinking of that, but it's important to just sort of ask a doctor explicitly and directly about that. Ability to me is obviously. I just think that that's the single most important thing. I mean, in the end, yeah, bedside manners, great. Affability is important, but I'll never take affability over ability. You'd want both. They're not mutually exclusive. But don't be confused by affability at the expense of ability. So we'll come back to maybe how you can assess ability. But that's important. Affability is like, do you get along with this person? And I think you should be able to get along with your doctor. I mean, I think the days of going to the doctor who talks down to you and is basically preaching a bunch of commandments, it just doesn't make any sense. You just don't want those kind of people around because, yeah, in the end, they might be the expert, but if they can't bring you along, then the relationship probably doesn't fit. And if I have a patient in which I feel like I can't bring them along or I don't connect with them, I certainly say to them, look, maybe this isn't working. And in the end, you maybe need somebody different from me who can communicate in a way that you like to be communicated with. Availability is basically. Or access is like, are you looking for someone that you can call 24 7? And that's when people are looking for concierge docs. That's generally what they're looking for. There are lots of non concierge docs, though, that still have. And within the world of concierge, look, you've got like the $30,000 a year concierge guys, and you've got the $3,000 concierge guys. And so you also have to be able to think about, okay, well, within that, like, what's the difference between those two? What's worth $27,000 more per year if that's the. And those are literally like, that's probably the range that I see in New York for concierge pcp. But I guess the person asking this question is probably thinking mostly about ability. I think, you know, the question included something about, have they read a medical journal in the last 20 years? I mean, that's a good question because so much of what we learn in medical school is pretty much irrelevant by the time we're practicing. And the lag between when something becomes a finding and when it becomes mainstream or obvious enough that everybody's doing it. I've seen that number estimated at anywhere from 12 to 20 years. So, yeah, it seems like a pretty inefficient system. So I think there you just want to talk to your doctor and say, look, how busy are you clinically? How much time do you spend reading literature? And again, I wouldn't use buzzwords like evidence. Do you practice evidence based medicine? Because what doctor is going to say no to that question? Like, it's sort of a silly question. It's, you know, it's like. So it's mostly just trying to inquire about the curiosity of the person, their passion around learning. Because I think in many ways, if you're not learning quite a bit as a doctor, you're probably not practicing great medicine. If you're not sort of trying to get smarter on diagnostics or, you know, advancements in the field, then you're probably stagnant. And it's not to say that a doctor who's stagnant can't do great work on certain things. But for most people, they don't want to have like six doctors in their life. You know, they sort of, you want to go to one person. So I think that's how I sort of think about that. Unfortunately, I'm not really a fan of a lot of the labels that people put on. Like, well, I, you know, I practice functional medicine or I've, I'm part of, you know, this organization or that organization. I just, I don't know. I think in the end you got to just evaluate the person individually, regardless of those features. And I don't know if that answers the question.

I think so. I think one of the things that I was thinking about is people will ask, people will be relatively specific and they'll say, I live in Boise, Idaho. Do you know a good doctor there? You may or may not know a good doctor there. However, it probably brings up the point that if you can get a referral from somebody that you really respect and think is a great doctor and knows their stuff, that a referral probably would be pretty valuable there too, as well. But it's very hard probably to refer somebody, if you're in your own practice as a doctor, to really vouch for somebody else across the country.

Yeah, I mean, my ability to do that is if it's going to happen, it's going to be by luck. It's going to be. I already have a patient there and they've got a doc who I've inter. Like I've patient in Seattle who's got an amazing PCP up there who I won't name now, or else he'll get inundated with a million people. But frankly, I think his practice is probably full. But every time I've had a patient move up to Seattle, it's like, that's going to be your doctor. Because the guy's like, he is the epitome of what a great PCP is. And I love reading his notes. I just, I love interacting with him and I love that, you know, we complement each other. In other words, there's a whole bunch of things that I do that, you know, look, he sort of knows a little bit about, but he wants to know much more about lipidology and cancer screening and, you know, some of the exercise stuff we're doing. But then there's a bunch of stuff he does that I like, his knowledge of. You know, when the patients travel to this part of the country, you got to be aware of this particular parasite that can show up. And here's how we're going to vaccinate you against this. And here's how we're going to. You know, you were in that cave in Texas. Well, you're very susceptible to this kind of thing. And just, you know, someone's got like a. An HSV flare and like, he knows all of the tricks. And so that's probably the easiest way for me to refer people is that I've worked with the doc directly. Going back to the point, though, I don't think people should be afraid of this process taking a while. In other words, if you. If you go down the path and you find somebody and you think, this is going to be my doc, and, you know, six months in, you don't like him or her, do it again. Keep doing it, Keep doing it. And a lot of the questions you ask the doctor's reaction to those questions is probably a litmus test. So if you sense that a doctor is put off by a curious patient who's showing up wanting to be actively involved in their health, well, then you don't want that doctor. You don't want someone who's intimidated or put off by your interest and obsession in this stuff.

As a patient segue into racing. You got a number of questions on racing. This one stood out to me. I'll just ask it first. What was the hardest thing for you to learn when you were becoming a driver? I suspect this is racing not when you got your driver's license, but you could answer that one, too.

Parallel park. I think the hardest thing is something that I still struggle with is. So when you think about driving, like, what are the sort of elements of it? The first, I guess, is sort of understanding conceptually what's happening. You don't have that many inputs when you stop to think about it. You have throttle, you have brake, you have steering, and you have shifting. So, you know, you have a clutch and a gearbox. Those are your inputs, those are your tactics. You go up and down on those things. Furthermore, you only have four contact points. You have four tires that touch the surface, and everything else is in service of those things. So. And then also in the spirit of fours, there are basically four things that determine how fast you're going to go, which is the tires, because they're the contact point. The engine, which provides the power, the chassis, which includes everything from the stiffness of the vehicle to its aerodynamics and its downforce, and then the driver. So you as the driver, make up one component of those four things that determines the outcome. You have these four contact points as the tires, and you basically have four inputs. So I think the first thing that one has to learn is vision. Like, you have to understand. Well, I guess the line vision I put together. So there's obviously a line that a driver takes. So if you're watching a race on tv, you're noticing that all of the drivers are driving in the exact same place, unless they're overtaking another driver. But there's a optimized, fastest way to go around any race course. And for every circuit that I would drive, either real or in the simulator, I know the line, like, inside. Like, I know exactly where the car needs to be at every moment in time. And I think for some people, that takes longer. For me, that was one of the few things that didn't take long. Long, because maybe because I'd already ridden a bike so much a bicycle. And in time trialing, where you're on these, every second counts, you learn exactly where the apex of a corner is, how to take a corner, all of those things. So I think that came to me pretty easily. In driving, you have two types of steering issues when you're going around a corner. Obviously, cornering is what makes driving hard. It's easy to drive in a straight line really fast, it's hard to drive around a corner really fast. And the two things that tend to go wrong are understeer and oversteer. So under steer is when the steering wheel is turning more than the wheels are turning. So that means that if you're trying to turn to a corner of the around the right, your wheels are pointing in a direction that is turning you to the right, but you're drifting to the left. So that's called understeer. You are steering less than you would like to. That is a relatively easy problem to correct. And it's also a relatively easy problem to see because where you're going is not where you want to be going. And that is almost always the result of too much speed. And again, for every situation, you have to decide, are you backing off the throttle? If you're on throttle, are you actually applying brake, etc. Oversteer is the opposite of that. Oversteer is the back end of the car is starting to come out from behind you faster than you want it to. So that means the car is now going to turn faster than the rate at which you've asked the wheels, the front wheels, to turn. Now, I think learning to correct and oversteer is for me the greatest learning curve, because it's not something for which the initial cue is visual. It's actually something you feel. You feel oversteer in your butt, because it's basically your butt and the seat are starting to go in a direction that you don't want to go. And there's a well understood way to correct an oversteer, but it's well understood conceptually. It's not necessarily intuitive. The first step of correcting an oversteer is intuitive, which is changing the angle of the wheel, the front of the car. It's the pause and the correction that comes after that is it's, it's like. And again, I'm positive that there are many drivers out there for whom this was a trivial exercise to learn, but for me, it was not. And in fact, one of the things that my coach had me do was he was like, look, you just got to get comfortable going sideways. And so he sent me off to sprint car school. You know, sprint cars are those huge wheels in the back, little wheels in the front, very small cars in terms of weight and staggeringly overpowered, but you're basically driving that car sideways. You're drifting the whole way. I was like, hey, should I go to drift school? And he's like, no, no, no. Go sprint car. I mean, that's where you'll really learn this stuff. I think the other thing that was hard to learn, although I'm so much better at it now that it's. I mean, not to say I'm good at it, but I'm so much better than where I started, is understanding how to modulate a 1 out of 10 response on the throttle and the brake. When you're driving on the street, you're not really thinking of that stuff. You're on the gas, you're not on the gas, you're on the brake, you're not on the brake. But in a race car, even how you come off the brake pedal, you know, if you're at a 5 out of 10 break, do you go 5, 4, 32 1, or 5, 31 off? And those will produce, especially at, you know, high speeds and with turns that will produce a very different sensation. In one of those, you're flipping the car around, and the other one, you're driving quickly through the line. And so learning how to modulate throttle and brake pressure and making those as smooth and elegant as possible, you know, that that took some time.

Sounds like playing an instrument. Not that I play an instrument, but if I were to play an instrument. Well, you'd probably have to know those things.

Yeah, I don't play an instrument either, so I can't speak to it.

But so on the, on the oversteer, just because I'm curious, I always think of left turns as in nascar, maybe just in my head when I'm thinking of turning. So if you're doing the oversteer and your butt sticking out, so the backside is moving out to the right, so you're oversteering. I mean, you're oversteering and you're moving too far to the left. How do you correct that?

So the first thing you do to correct an oversteer if you're in that situation, is you actually jerk the steering wheel to the right to flip the front of the car. And then you're basically going to pause for a moment and let it correct and then come back onto throttle and pick it around. And so when you Watch. Look at. You know, there's a guy named Chris Harris. There's lots of guys online that, you know are great to watch, but Chris Harris is one of my favorite drivers. And he's like a drifting machine. I mean, this guy, he's really got it down. But if you want to be able to drift a car, you basically have to put the car into an oversteer and then hold it there for a long period of time. So one of my favorite videos is Chris Harris Drifting, one of the 911 GT3.991. So, of course, maybe we'll find the video and link it to people. But he's test driving, like, the first generation of the GT3RS. This is probably like 2015, and I think he's at the Porsche circuit, and there's this one turn where it's like one of the most beautiful examples of a controlled oversteer drifting around. And it's one of those things when if you watch it and you're not a driver, they make it look really easy. When I watch it, I'm just going, God damn it. How does he do that? Like, because I'm actually watching the micro adjustments of his hand, and I'm like, he is so talented. I will spend the rest of my life trying to become half that good.

Speaking of talent, one of the questions is just comment on the reasons you are a great fan of Senna.

You know, I mean, I think Ayrton Senna is probably considered by many people to be the greatest race car driver ever. He died, of course, quite tragically and quite visibly on May 1, 1994 at Imola in Italy in an accident that is to this day, still debated as to the cause of it. Though I have very strong point of view on what the cause of the accident was. You know, I think on many levels. One, he was just so naturally gifted. I was talking, actually was one of my patients the other day, and he was telling me a funny story about how he. I don't remember the connection. It was like his girlfriend's brother or something like that. You know, grew up in the uk, was, you know, like a guy like me, like, not as not a professional driver, but a guy who really took his driving seriously and had spent years and years trying to hone this craft. And one day he's at a track and he finally lets off his absolute fastest lap of his life in this car on this track. And this was back in 1980, and there was this kid there, and they were like, hey, can this kid Go take your car around for a spin. You know, he's never been on this track before. He's never been in your car before. And he said, yeah, okay, whatever. So the kid goes out and went six seconds faster than he had just gone and smashed like, which was then faster than anyone had ever driven any, you know, that type of a car on that circuit. And of course, the kid was Senna. So there's just this raw natural talent. The other thing I think, is just this incredible passion. You know, there are some drivers like Schumacher, who you could equally make a case would be as great a driver and certainly by number of championships will be the greatest driver, but, you know, had a much less emotional way of going about things. I also think just what Senna stood for, both, you know, on and off the track. I mean, I think many people were not even aware of how much he cared about Brazil and the people of Brazil until after his death, when people realized how much of his enormous wealth he had contributed to, you know, fighting poverty in Brazil. And to this day, the Senate foundation is kind of a remarkable organization there. I'm constantly moved by the response that anyone from Brazil has to Sena. Our nanny is Brazilian, and I don't even think she was alive when Senna was. When Senna died. But, I mean, she knows everything about Senna. We talk about Senna all day long. My son's name is Ayarthan, so, you know, she just loves taking care of little Eri. I was in an Uber two weeks ago up in San Francisco, and, you know, the guy had a Brazilian flag all over the car and blah, blah, blah. And of course, we got talking and. And he started asking me about this, and then five minutes into the discussion, he goes, wow, you're really a Senna fan. And I was like, well, yeah, I mean, that's all we talked about the whole way to the airport. So, you know, that you could still find something to talk about with so many people. It's sort of amazing. And I think many people look back at the era that Senna raced as the golden era of Formula one, because it wasn't just that you had Senna. It was that you had Prost, you had Mansell, you had Piquet. I mean, you had amazing drivers in an era where the drivers mattered more than they matter today. And that's not to take anything away from Hamilton or Vettel or, you know, any of the great drivers today. And those two are amazing drivers. I think Lewis Hamilton's probably the best driver today, but the cars are so Much better today than back then. So much safer. They have so much more downforce. Back in the late 80s and early 90s, I mean you were basically riding on mechanical grip alone. And when you look at videos of these guys driving, you know, they, there's just amazing things. And then of course there's like, God, I think it was 93. There's this very famous lap at, I think it was at Donington where Senna started in the four position, meaning. So he was fourth on the grid, so didn't have a very good qualifying and by the end of the first lap he was in first. That, that we should also link to that.

I remember you sent me that link.

Yeah, yeah, that's like you'll never see that again. That was sort of considered the greatest lap in the history of motorsport. Of course the other thing that I think is amazing is his qualifying time in Monaco in 80. God, I was at 89, maybe 88, where he qualified about a second and a half faster than Prost. And Monaco is a short fast circuit. On the longest circuit you could never see a second and a half difference. When you see. So you know, in racing we measure things on the qualifying lap. They're measured to a thousandth of a second for a reason. There's a reason it's not to the tenth of a second, you know, because the difference between 49, 47 and 49.49 is pretty big and those would otherwise both be 49.5. But when you're qualifying ahead of a four time world champion, which Prost was a second and a half faster, you're just playing a different game than everybody else. You know, Senna won three world titles, although I will always maintain that he won four because in 89 he was disqualified in the final race in Japan for reasons that I think are completely political and completely bullshit. So as far as I'm concerned, his disqualification was nonsense and Senna was. Senna died as a four time champion. I'm convinced had he not died in 94, he would have won the world championship that year. No question. Even though it was the Williams 15 car that they were in was having trouble. But the fact that Graham Hill almost won. Damon Hill. The fact that Damon Hill almost won that year as the number two driver tells me that Senna would have absolutely won and probably would have been incredibly competitive for the next two years. So, you know, had Senna not died, I mean, you know, he could have easily had those seven world championships that Schumacher had. But yeah, he'll just forever sort of Be my favorite. And I love like, I mean if anyone hasn't, if anyone's watching this and is even remotely interested in this stuff and they haven't seen the documentary Senna, it's such a big beautiful.

I was going to ask if that would be the one that you would recommend. Covers a lot of this.

Yeah, yeah, yeah, for sure.

Another racing question. This is a simulator question. How does iracing improve your real world racing skills? And could you do more official races or races with fans also? Favorite car.

So iracing is a software program which you run in a simulator. You don't need a simulator to run it. You could probably just run it off your PC and play with like, you know, toys but in a simulator. It's really designed for a simulator because of how high end it is. I think that iracing is good for every element of driving. But it does have a couple of drawbacks. The first is we were talking about oversteer earlier and you'll remember that I said that oversteer is not as visual as understeer and that oversteer is something you first feel. The simulator can't really capture that. So when I'm in a car and I oversteer, it's much harder to correct in iracing because I lose the warning. I only know it's happening when I actually see that I'm spinning. So it's not that it can't be corrected, it's just, it's harder. So it throws your timing off a little bit and what your correction looks like. The other thing that you know, obviously a simulator doesn't do compared to being in the real car is you don't have the same thing physiologic stress. So I probably have more seat time at a course called Button Willow because it's relatively close, meaning it's only like four hours away. But it's in Bakersfield and I like to go in the summer because nobody else likes to go in the summer. I can't understand why. And it's hard. I mean it's, it's, you know, you're in a fire suit inside of a closed cockpit car when the temperature in the shade is 108 degrees Fahrenheit. It's probably 130 in the car. You know, it's like the little stuff like what do you do when you can't keep the sweat out of your eyes? What do you do when your core body temperature is 2 degrees higher and, and what do you do when the dust is blowing in and blah Blah, blah, like, you know, so, so you can't. That's just. And to be able to concentrate through that takes practice. And you don't get that practice in the simulator though. I do. Like, I'll wear my helmet in the simulator and, and do it in a room that's hot and try to mimic some of that stuff. Where the simulator is incredible is just the economics of it. Every day you're in a race car on a track, it's thousands of dollars. It's just unless you're incredibly wealthy, it's cost prohibitive to really learn how to drive a car well in a car. So just like pilots spend most of their time in simulators long before they're up in the air. It's the same thing. And so when I want to learn a new car or learn a new circuit, I want to get a few hundred hours of that on the simulator before I go there. And it makes the experience much richer. And if I don't have that luxury, for example, Button Willow is not in iracing. So the first time I drove Buttonwillow, I ended up having to watch tens of hours of onboard film of drivers driving Buttonwillow. And even that just couldn't prepare me for it the way driving in the simulator could. As far as my favorite car in the simulator, it really depends on what itch I'm trying to scratch. If I'm trying to go as fast as possible. It's the Pro Mazda, which is not the fastest car in there, but obviously formula cars are much faster than closed wheel cars. And you know, they do have a Formula One car in there. I think they have the MP430. It's just still too fast for me. So even though it's a faster car, the thing's outrageous. So that. But the Pro Mazda, like I'm getting to the point where I can drive that car relatively close to its limit, probably within 1 to 2% of its limit. As far as closed wheel cars, it depends. Like relatively aggressive and not that difficult to drive closed wheel car in there, but it's amazing how fast it is. Is the Ferrari 488 GTE. It's a beast. And I like the RUF 911, which is actually really hard to drive, but it's so freaking powerful. And it's like that's a car that will punish you, just punish you if you make a mistake. And there's something, you know, if you're going to get punished, I'd rather get punished in the simulator. So it's nice to Learn that. But honestly, like, you know, even driving a Miata in the simulator is still a blast. Cars are just fun to drive.

So there's one more question. It's related. It's curious what your choice of daily driver is.

It depends on what one's optimizing for, I guess.

Groceries.

Yeah, exactly. If you're optimizing for groceries, for being able to, like, pick up your kids, if you're being able to, you know, like, I used to drive an E92 M3 and that was amazing because it had such a big. It had a big enough trunk that if I took both wheels off my bike, I could put my bike in my trunk. And that was essential when I was like, riding my bike a lot because, you know, three times a week I'd be training at a remote location where I had to take my bike. So, you know, to have a car where I could easily move my bike was. Was a given. You know, fortunately, if there's one thing that driving in a race car has done is it's made me less of a knucklehead driving on the street. So I don't feel quite the need or the desire to drive.

More speed.

Yeah, exactly.

I thought you were setting me up. Never going to high five Top Gun.

You know, they're filming a second Top Gun.

I'm told, miss on the top, hit on the bottom.

That's the only way to do it. The word on the street is they're filming Top Gun too.

I heard.

Heard that, yeah. Yeah. I can't wait to see iceman. I love 911s. I think they are great. I think no car really combines the practicality of you can drive this car every single day. And it's really fun to drive. So it's like, I call it sort of a civilized beast.

So you mentioned putting the bike in the trunk of the car, which kind of gets to exercise. You got a bunch of questions about your exercise and exercise in general. So let's go with your exercise in terms of. This is a question about open water swimming. The question is, knowing what you do now, how would your preparation for those long open water swims have changed? Still as many hours in the water prior to a big event, Would your feeding strategy be any different?

Yeah, I probably would have still spent the same amount of time in the water, but that's because I was not a natural swimmer. And, you know, I was still at a point where even just basic stroke mechanics were not automatic. So, you know, if you remember, I talked once about this idea of being unconsciously incompetent. Consciously incompetent, consciously competent and unconsciously competent. I never got to that fourth stage. So I would vacillate between stage two and three. So I think, you know, I probably just needed the time in the water. That said I would absolutely be feeding a lot different than I fed at the time. I was feeding exclusively on. What the hell was it called? Well, one of the. I use hammer strength. Hammer perpetuum, I think it was called, not hammer strength. That makes the gym equipment. I think the. I think it's called hammer perpetuum, which was probably the least bad of the high carby fuels. You know, it was maltodextrin based and then I used something that began with a C, like cyto Mal. Cytomyx. Cytomal is like thyroid hormone. Didn't use that. Yeah, I think it was called Cytomix. And I would supplement. I put some stuff in it. I don't remember. Oh, I would put in. No, I would. There was a drink in the UK called Maxim that was a flavorless maltodextrin. I would add that to. I would vacillate between the hammer perpetuum and the Maxim spiked cytomax. That's what I used to use. And I think what I would do different today is I just wouldn't be a high carb diet. I would be a highly, highly fat, adapted, totally different strategy and, you know, rely as little as possible on glycogen for what I was doing. So when I was swimming, my RQ was probably 0.85 to 0.9 most of the time. So meaning I was relying on. More than half of my energy requirements were coming from glycogen or glucose and by fat adapting. I would, I'd like to, you know, have done those swims at an RQ of 0.75, which would dramatically decrease my requirement. I would probably then instead be using generation ucan. I'd probably use a bunch of biosteel as well. I think that was something we weren't paying enough attention at the time to the importance of branch chain amino acids. So that's probably how I would change now. I'd have to sit down and do the math and experiment at what amounts I would need, but I would probably do. Yeah, I don't know. I could think of two different ways I'd experiment with it. One would be doing more concentrated, less fluid requiring, especially on the cold water swims where you're not getting as dehydrated and then minimizing the feeding, because I used to feed, I think every 20 minutes and I'd do about 250cc every 20 minutes. And I might change that. I might have gone that, I might have knocked that down to like 250 every 30 minutes at a lower concentration of alternating you can with biosteel or something.

This is a naive question, but how do you refeed and drink while swimming?

So it depends on how fast you're trying to go. If you're trying to really go fast. So you have a kayak on the side of you and you're swimming. So if the kayak's on your left, when your right arm is in front of you, arch over and you with your left hand grab a bottle that's on a carabiner on a rope and you flip on your back, the bottle's already opened. You chug it and drop it and rotate and keep swimming. And it should take about seven seconds to do that. So that's if you're hauling ass. If you are exhausted and you need a break or you need to also pee, you just stop and tread water and grab it and do it. But you can't touch or be touched by the person in the kayak or the boat or anything like that. So that's why we would use these bottles with loops and carabiners and ropes. And we had a big elaborate system. In other swims where I didn't have a kayaker, we built this pole, long ass pole that had a little cup at the end.

It's like a fishing pole.

Yeah, exactly. And you know, so. And they'd shimmy that thing out from the side of the boat and you'd. For the pole, you couldn't do the rapid feed. It's just too, you know, too many moving pieces. But you could, the rapid feed you'd be taking, the kayaker would be standing with their. Or would be in the kayak with their arm out to their side perpendicular to create the most distance so you could come up and grab it. I really loved practicing that. That was like my favorite little ninja move.

Interesting. It sounds a lot different than the. At least when I would, I would watch the Tour de France, I think they call them the Musettes and the slings. The danger there was that people would stand in the middle of the road, the peloton going by, and it was like a magic trick. You would just see it would, it would be gone. And whoever carried the sling would carry the food and carry the food to all the different people. But that's a Different ballgame.

Yeah, that, that's real skill.

So what do you do for exercise these days if you're not open water swimming?

I still lift weights three days a week. That's kind of like the one staple thing that is non negotiable in my life. So no matter how busy travel gets or wherever I am, I'm always going to be in the gym, sort of Monday, Wednesday, Friday, lifting, plus or minus some metabolic conditioning thrown in there. Depending on what else is going on these days. I am on the other four days, the Tuesday, Thursday, Saturday, Sunday, I'm riding either the peloton or the Wahoo kickr, which is like a trainer that you put your bike on and hook it up to something called training. No, I ride trainer road actually, as the program that then generates the workout. I have not swum except for a month where I started swimming again in February of this year. I have not really been in the water in a year and a half, which feels really odd given how much swimming was sort of everything in my life for so long. That's probably one thing I'd like to figure out. A way to reprioritize is to get back in the water even twice a week. I miss it so much and I think there was something, yeah, there's just something in my body misses about that. I also had picked up running again probably three years ago and really started to enjoy it again. It took a year to start enjoying it again. It was that painful for the first year. And then once I started to enjoy it again, I really, I got the itch to hey, could I maybe get back to running, you know, a 5K under 18 minutes or something like that. But then, you know, I just got distracted and that's when I kind of got back on the bike. So the bottom line is I don't actually train, I just exercise. So I don't actually do anything that's impressive. I just sort of do my little putts workouts and I also spend a lot more time on movement prep. So, you know, I take the sort of flexibility, movement correction stuff a lot more seriously than I ever did because I've sort of seen the impact of that on injury prevention and the absence of that on injury generation.

And you've never done a triathlon, is that right? So you mentioned, you mentioned run, bike, swim.

That's right. I've done all three of those things at one period. I mean, I was a pretty decent runner in high school, a pretty decent cyclist probably during two periods of my life, at least as a Time trialist. And that's basically what a triathlon is. And pretty good open water swimmer. So yeah, in theory, if you could have taken me from three different chapters of my life, I could have at least done a triathlon. I don't know that I could have ever done it at the level of the guys who are really good. I mean I have friends who are in the 8 to 9 hour Ironman category. I don't think that's even theoretically a number I could have hit. I'm not even. I remember one day sitting down and really like going through like what I thought physiologically could be done. I wasn't even sure if I convinced myself I could break 10 hours for an Ironman. And again I think when you're doing an Ironman, I think for many people the goal is just to finish the thing, not to break 10 hours. But when I see these guys out there that are breaking nine hours on Ironman, especially people who aren't professional athletes and you know, I have friends that are at least two friends who have broken maybe three friends now that I think about it, who as non professional athletes have broken nine hours on Ironman. I'm in total awe of that. That, that to me is, that's a remarkable achievement.

The distances are. You're running a 26.2.

Yeah, you're swimming, you're swimming 2.4 miles which is, that's a rounding error. You don't even. You can't win the race in the water. You can only lose it. The bike is 112 miles and then the run is 26.2.

Looking at exercise in general, a lot of people ask what's the best exercise for longevity? What is the best exercise to improve muscle mass? And can you expand on lifting weights? Your entire life is something you should never stop doing. So exercise for longevity. Exercise to improve muscle mass and expand on lifting weights.

I think the exercise for longevity is a hard question because I don't think we really know the answer. So instead it's probably easier to bifurcate it into two questions, which is exercise to improve lifespan and exercise to improve health span. So how does exercise improve lifespan? Well, it would have to somehow positively contribute to the delay of or to delaying the onset of atherosclerotic disease, cancer, neurodegenerative disease. I think there's plenty of evidence that suggests that exercise is beneficial in all of those arenas. And then I think the question is through what mechanisms? So that you could then go from saying exercise to understanding specifically what it could Be so cognitively, we probably see some benefit from a certain subset of hormones that basically does bdnf, for example, increase with exercise? And what is the impact of that that's going to have on brain health, on the cardiovascular front and also on the cancer front, My guess, and I think this is true on the dementia front. I think that anything that exercise does that helps you dispose of glucose more efficiently and helps your muscles become better sinks for glucose is probably going to improve things. So I think taking that off the table, because I think that's sort of the one given the question is, are there benefits on the cardiovascular system specifically from exercise that go beyond that? And I think the answer is probably, probably yes. Like everything there's a dose, you can also probably exercise too much. And there's probably like all complicated questions. There are people who are more susceptible and less susceptible to the effects of too much exercise. There are people who can get, you know, a certain dose of exercise provides all they need. But that said, I think even more of the benefit of exercise is on health span, meaning enhancing the quality of life. And that's cognitive, but also physical. I think too many people confuse healthspan and lifespan. And you hear too many people say I don't want to be old because I don't want to be decrepit and et cetera, et cetera. But to me that's sort of like an odd statement to make. It's like, why wouldn't you want to be old and be fit? And don't just accept that getting older means not being able to, to do things. So, you know, at about the age of 40, it starts to become much harder to maintain muscle mass if you're not deliberately doing something about it. And so that's why I would say lifting weights is probably the single most important thing you can do. Because I think that muscle mass as you get older becomes an enormous difference between people who are frail and people who are not. And other things matter, of course, certainly bone density and things like that matter. And, you know, getting into how you can optimize those things is beyond the scope of this question. But even within lifting weights, then I would say that, you know, rule number one is don't get hurt. So you see a lot of people, especially younger people, doing things that they don't need to be doing. Even I've sort of adjusted what I do relative to what I used to do, just based on the trade off. So I use a hex bar to deadlift instead of a straight bar because frankly, it's a bit easier, you know, it's just, it's easier, it's easier to use my glutes and you know, I feel like I'm much less likely to hurt my back. Are there benefits of a straight bar over a hex bar? Sure. But the benefits to me aren't worth the risk when I back squat. Pretty rare that I'm going to go over 275, even though as a high schooler I would put four plates on that bar. But again I, I don't power lift. I don't, I'm not competing. Nobody cares how much I lift except me. And I'm not even sure I should care that much. So it's. So I've taken a very different approach. I don't overhead press at all. I only press with dumbbells now, not barbells. Even when I'm doing like, you know, any, you know, bench or incline bench or anything like that. So all of my overhead shoulder work is now stability work. Everything that's going to work shoulders below is done below the shoulder. And that's had a huge impact on my shoulders. Like they just, and they're totally fine, you know. So you have to learn to make compromises as you, you age. But you shouldn't, at the same time, you shouldn't compromise the, the expectation that you will be strong. You should be able to walk through an airport and carry two 50 pound bags if you need to. Because if you can do that, if you, if you're already struggling to do that in your 40s, you're gonna have a really hard time whipping your grandkids around when you're in your 70s. So it's sort of like how do you minimize how quickly you're going to decline?

We went over wearables, but just for the record, what wearables do you use? That's the other question you've mentioned. Wearing a glucose meter. What devices are out or on the horizon that you'd recommend for more instantaneous feedback than just the scale? I think we got the answer on the cgm. And how well does the OURA ring hold up? Doing pull ups, working with barbells, dumbbells. Do you use something else for tracking while training?

So going back to the CGM thing, there really are three out there. There's Dexcoms, there's the Libre by Abbott and then Medtronic has one. I don't think anybody's really using the Medtronic socially. So it's mostly the Dexcom or the Libra. The Libra is Cheaper, I believe, and it doesn't require calibration. But other than that, I find it not helpful because as I said, in, in our hands, both individually and with patients, I think we're seeing accuracies that are plus or minus 20%, which I just think is, that's not good enough. The Dexcom G5 was about plus or minus 7%. The G6 I think is probably plus or minus 3 or 4%. It's so accurate. And of course the challenge is it'll be a long time, truthfully before these things are cheap because right now they're not really being targeted towards a consumer market. They're medical devices. And so the economics of these things are very different. They're going through a huge regulatory. I mean the FDA really scrutinizes the way these things work for understandable reason. Because if you're going to have a patient dose their insulin based on this thing, it's got to be exceptional. My hope is that in time, as the demand for this in the public increases, there become second tier versions of these things that it's complicated because of course the thing the FDA would always be concerned with is if we allow a less robust version of this to go on the continental consumer market, will it invariably end up in the hands of people who actually need the more robust version and then make the incorrect diagnostic choice? That's the thing that would keep you up at night if you were doing this. So again, that's just beyond my pay grade to figure out how to solve those problems. But I certainly hope that there's a day and it's, it's probably four years, five years from now when the CGMs are really tiny. You've guys basically the size of a contact lens. It's a tiny patch. It's a, you know, 400 to 1,000 micron needle that you just smack on your belly every day and you just dispose of it and away it goes. As far as the Oura ring, you know, I think I've tried every sort of sleep device out there and I just don't think any of them compare to the Oura ring in terms of its accuracy. And in part that's because it's measuring off an arterial waveform and I think their hardware is better and stuff like that. The only activity I have found that I have to take the ring off for is deadlifts because most other things aren't, you're not putting that much weight on it. Like even if you're a pull up is only your body weight even if you're doing a pull down like on a machine with more than your body weight, it's not, at least unless you're Bob, that's it's not that much more than my body weight. You might not be able to wear one with your pull ups or with your pull downs, but I have, I cracked one doing deadlifts, so. And I think that's just because it's just sitting right there. But most other things, like even with heavy dumbbell presses, it's not really where the weight sits. For me, your finger is actually above the weight and the weight is being rested on your palm. So I can't think of another exercise I do. If I hit the heavy bag, I'll take it off.

So I've got another bucket here. Going to keep going.

I got a little bit more juice left in there. Does that mean we're not having fun?

I was worried that we would spend way too much time on this, on a lot of the stuff here too. We can get into some of the other topics too. That would require another two hours per topic. This one could be one of those. Although we might be able to do this thinking about thinking, learning about learning. So there's a few questions here. What is your strategy for learning something deeply?

Yeah, this is like a better question for Tim Ferriss. I mean, Tim's codified this stuff.

Do you have a particular strategy or how does it go? Is there something you want to know about?

I only know one way to really learn things, which is not necessarily efficient, but it's just basically total immersion. It's probably not an accident that when I wanted to learn how to swim, I went to Terry Laughlin and learned to swim via total immersion.

So when did you learn how to swim? When was that?

I was 31, 2004.

So when you got into open water swimming, when you realized you wanted to get into open water swimming, you didn't know how to swim, Right?

I had to learn how to swim.

Okay.

It's a necessary condition. So I remember in 2011 when I became maybe 2010, 2011, when I became really interested in lipids, just basically realizing, looking at my family history, I'm probably going to die of heart disease. That's sort of how almost every male that I'm related to has died of heart disease. So I knew enough to know, one, I probably don't know the answer, and two, I should learn about this. And that's when I met Tom Dayspring, who became my first teacher on this topic. And since that time remains Unquestionably the greatest mentor I've ever had in this space. And I've also got to know guys like Ron Krause and Alan Snyderman and Jamie Underberg. I mean, I could just rattle off the names of all of these guys. Tara, Dahl, they've all been incredibly gracious with their insights and their time. But yeah, the approach I took was just like, give it to me all. Don't try to give me the Cliff Notes. Just, I'm going to fricking learn it. And at one point, I even contemplated going back and doing a fellowship in lipidology. But of course, the problem is I couldn't as a surgeon because I had to go back and do internal medicine. You know, I would have to go back and spend two years doing internal medicine. I'd only get one year credit for surgery. So I realized, no, I don't need to become a lipidologist. I can just learn what the lipidologist knows. So it's reading papers, it's watching lectures, but in many ways your learning comes from doing so. I think some of the most interesting things I've learned have been a privilege of just taking care of somebody, you know, so you. So you see a complicated case. Some of my most interesting lessons have been reviewing cases with Tom or Ron or Alan. You know, I went out to visit Tom. I remember once about two years ago, for two days, and all we did was review cases for two days. And every time we saw something that was like, particularly interesting, he would like, because he's Tom, just bust open a lecture on that entire topic and then we dig super deep into that stuff. So I think that's just kind of the way I learn. Same sort of approach with trying to learn the hormone systems and learning to drive a car, for that matter, or whatever it is. It's sort of like you just got to get. At least for me, I don't think I'm a particularly efficient learner. I'm a brute force learner.

You revealed something. Tim's probably talked about this, that if you want to expedite your learning, find somebody who's basically already done exactly what you're saying. So what is your strategy for learning something deeply? You basically grab the person who's probably learned this stuff at the deepest level and you don't let go. You try to extract as much information as possible from that person who's already gone through the process of trying to learn whatever the topic is very deeply. I think that's a.

Especially if their way of teaching resonates. With you, math is complicated once you start to get outside of the basics of calculus and algebra. And I just remember there were some professors that they just had a natural way of. At least the way they explained something was the way I was wired to hear it. And then there were others who were brilliant, but I didn't have a goddamn clue what they were talking about. Like, I could never really learn from them. So part of it was just knowing how to pick and choose your shots and, like, who are the people that are gonna be. Who are gonna resonate with you? And it's not necessarily the person who knows it the best. It's the person who can teach it the best, at least during that phase. And then maybe as you get further down, like, I don't think anybody could have done for me what Tom did at the outset. Cause I just don't think anybody has put that much thought into teaching lipidology in the world. I mean, I really mean that now that I've been at this for quite some time. I don't think anyone on the planet has put more time into teaching and educating and codifying the insights of lipidology and the science of lipoproteins than Tom dayspring. Now, there's surely somebody out there who knows more than Tom about this stuff, but I can't imagine there's anybody who's thought more about how to teach it. So it was just luck. I mean, just purely luck that I could fall into sorts with a guy like Tom and others like that.

Well, I think it's. Could probably maybe call it the reverse Feynman, But Feynman talks about how to learn something, and it basically comes down to being able to teach it to somebody who doesn't understand it. And you've kind of taken the inverse in some ways too, where you look at teachers and it doesn't necessarily matter what their level of understanding is of that topic. If you're not clicking with that person and it doesn't seem like you're extracting much information, whether you're not a good student or that person's not a good teacher, I think you're relatively quick to say there's more stuff out there that I could probably latch onto. And today with the Internet, I sound like I'm about 100 years old. But with the Internet, you go on YouTube, you can download lectures of all.

These different people with the Google and.

The YouTube, with the interwebs, the twitters.

Twitters with all the GBS and the WIFIs.

The problem is it's too much information. So part of it is trying to figure out the person teaching this to me, do they know what they're talking about? Hopefully they do. But then ultimately you have so many different avenues in so many different venues in terms of media. Can you listen to it or do you read it or face to face? Does somebody teach it to you where. I think the answer can be kind of customized to whoever asked that question about your strategy for learning something deeply. I don't think that there's necessarily.

Well, there's another thing I've done which I'd be remiss to not mention is at some point I've just hired people to help me learn. I mean, that's what you lead is a group of people whose job is to basically help me learn. It's to basically shortcut the system and cheat by saying, bob, we have got to know everything about IGF, IGF, BP3 and growth hormone. I don't have the time. If I'm going to learn this in detail, it will take three years. If you're going to learn it in detail, it will take three months. I may never actually get to know it as well as you because you will have done all of the heavy lifting and you will have turned tens of thousands of pages into 50 or 100 pages. For me. And I know, having been the guy that once made those 50 to 100 page synthesis, that the devil was in the details. And I had so much nuance around it that I will now give up. But in an effort to geometrically increase knowledge, that's probably a price I'm willing to pay. Let me turn the question to you since you have more experience doing this now than me. When Atiya calls you and he's like, bob, dude, we got to know everything about X, what do you do?

Some form of total immersion. What I typically try to do, I'm trying to think of some of the stuff. Like Tom 40 is a good example.

Yeah, so that was about six a year ago. We had to know everything about Tom 40 and its relationship to Apoe 4.

And I knew nothing about it. And I still. There's probably plenty to learn about it. But a lot of times what I'll do is I'll try to find either a paper or usually a paper because the lectures are actually usually simpler to understand. But something that's kind of complex and I read it and just go and.

Do you specify like a review article that you want to start with or do you want to start with primary research?

I typically, I'LL go to a review article that's covered all the stuff that's relatively technical, and I'll read it and I won't understand, I don't know, 90% of it or something like that. But part of it might be just the mindset or the mentality that I think like, wow, this is going to be great when I know all this stuff and then I try to immerse myself in it. Probably it's like a combination of stuff. YouTube, the lectures, if you can find. This is one of my hacks. I think that's kind of a pejorative. I would say that I've learned that some of the best researchers, when they give talks, they're not necessarily speaking to their colleagues and just geeking out on this stuff. They have to explain it at a lower level. And so I'll watch something, I'll try to watch like the simplest or the easiest stuff or it's way oversimplified. And I'll watch that lecture and I'll pick something up. And it's probably like learning a lot of things, whether it's a sport or an instrument or things like that. Maybe it's like a little dopamine hit or something that you pick up something and you feel like you're actually learning something and you can now read a sentence in that deep review paper or one of the experiments and you actually understand what it means now at some level. And then I'll try to find a great book on the topic, which for Tom 40, I don't know if there is one.

All those of you out there listening, looking for a book to write. It's the Tom 40 story. Yeah, two M's.

So usually most other topics usually be able to find a good book and something that's like a relatively fast read. Sometimes you get very lucky. And Sid Mukherjee writes the biography of cancer and you want to learn about cancer and you feel like you're reading a novel, but you're actually learning. You like the best kind of learning is like you don't even realize that you're learning. It's just like it seems like it's entertaining. That's probably why sometimes I gravitate to some of the YouTube talks and the people who are good at teaching those things.

That's sometimes why when I ask you for a short overview of something, you send me 154 page document on it.

Yeah. And it's probably a sign that I don't understand it all that well. That's the Mark Twain quote that you sometimes Talk about, if I had more time, it would be a shorter letter. So to be able to synthesize it and condense it is a challenge.

So I guess being very specific, now that I hear you say that, it reminds me of other tricks that I would use. I definitely like to start with the most recent review article on a topic. I never want to start in the primary literature because it's too narrow and I want a larger overview. So, for example, like, if tomorrow I decided I didn't. If I didn't know anything about LP and I wanted to start from scratch, I would, you know, go into PubMed and search LP Review. If I was lucky, I'd know who the players in the field were. But generally, by looking at the citations, you'd pretty quickly figure out, Sam Tamikis is God. And then I would look for the last three review papers Sam Tamikis has written on the topic. I would start by looking at the figures. Once you understand the figures, you actually know what's going on. And then from there I would go, and of course, the other thing I do is I'm just kind of a pushy little prick sometimes. I just don't hesitate to reach out to people. You're the same way every week. You're emailing the author of some paper. And honestly, I think that they never view it as pushy, even though we feel like, oh, are we being too obnoxious by bugging them? But the reality of it is they love it. This is their life's work. There's like one other geek out there who wants to know everything about their life's work. I don't recall you ever getting a response to one of your emails where someone says, piss off.

No, I mean, sometimes I may not get a response at all. And I just, I figured some of these people are massively busy, but otherwise it's the opposite, overly helpful.

You think, wow, so that's another shortcut, right? It's like, okay, you figured out who the expert is. You've read the review papers, you've got the 80, 20 view. Now you look at the experts to help you get the last 20%. Now you want to go 20 80.

Yeah. And for me, it's different than, say, my wife, who's a journalist. She doesn't mind not knowing a lot about a topic and just finding an expert, grabbing them and asking a lot of questions. I think this is like my ego maybe gets in the way or something like that. I don't want to talk to Sam. I don't know if he's going to say his name right, Tamikus, until I feel like I have a pretty good grasp of what's going on. And this guy's not going to think, what an idiot. But the reality is he's probably not going to think, wow, what an idiot. He's probably thinking like, this guy's taking an interest in this topic. It's really interesting. But that defense mechanism, I think maybe has helped me in research in some ways, where I think I really want to know my stuff before I contact the researchers. But then when you do, they'll usually give you more insight, better insight, and a different way of looking at things. And even with the papers themselves, oftentimes when you talk to the author, you get a different perspective, even from you.

Read Word for Word.

You read the paper, but they tell you about all the sort of like how the sausage is made and the.

Things that they had to take out of the paper because maybe they didn't have enough evidence to support it. Or the editors were like, the paper's too long. You got to take this out. Yeah, you're going to get a much more interesting story.

Yeah, I don't know if that was helpful, but I think part of it is you really, whatever it is you really want to have to, you have to buy in, I think, as well, because I think a lot of people are looking for a shortcut maybe, but a lot of what you're talking about too, with exercise and research and things like that, where you get immersed in stuff like it's sort of carry water, chop wood and don't stop, just do it relentlessly. I mean, it doesn't have to be burning the candle at both ends necessarily, but it just has to be continuous and relentless. And you have to keep moving in one direction, I think, and you can take a bunch of different approaches, but you really have to want to learn this stuff. There's just so much information about virtually everything that you would want to know. You can get like a free education that's probably better than any education that was out there, other than the people that you can meet and talk to. And I think that that's huge. So this is sort of the flip side. In your life to date, what did you waste the most time doing and what do you wish you'd done with that time instead?

This is going to sound like a shitty answer and a cop out, but I really mean it. It's not any activity or thing that I've done I don't regret. All the time I spent Boxing and doing martial arts, even though you could argue that I'm worse off for the concussions. I mean, I had some bad ones, really. I had one really bad one where I was hospitalized and I'm convinced I'm 20 IQ points lighter than I should have been as a result of that. And so it'd be easy to say, well, I. And I. And I've at times thought, oh God, I wish I why didn't I just play basketball instead or something where I didn't like get brain damage? But I don't because I know that boxing without boxing, I could have never done what I did after. You know, I could have never gone to college without it. In terms of the discipline it taught me. What I really regret is the time I've wasted thinking about things I couldn't change. It's the amount of time and energy I have wasted on things that don't matter. And I don't mean that in activity, I mean that in dysfunctional emotion. You know, it's the amount of time I thought about that ex girlfriend and, you know, for a year pined over her, her and wondered, you know, why she dumped me or something like that instead of just moving on, you know, or the amount of time that I spent pissed off at that person who did something bad to me. I actually think that that's the shit we have to be guarded against. Did I watch too much TV as a kid? I don't know. Probably not by today's standards, but yes, I've thought many times, oh, I wish my parents forced me to learn six languages when I was a kid instead of letting me do any dumb shit like playing with firecrackers and running around the neighborhood or whatever. But you got to be careful with those things. You know, Maybe I'd be a different person today if I'd been, you know, raised in an environment where my parents were constantly forcing me to be hyper efficient or whatever. So yeah, look, I wish there were many things I had spent time learning that I didn't learn. But at the same time, I'm not sure I'm willing to give up the six hours a day, six days a week I put into training when I was growing up, but I think I've wasted way too much time worrying about things that don't matter, worrying about things I can't change and not spending enough time in the present with the people who are sitting right in front of me who matter. That's probably my biggest regret on that front.

What impact did your upbringing have on your Insane career path slash constant drive.

Oh, this is a tough one. I don't know if I can talk about this shit publicly. I think I would just say this. I think I am fortunate that I found largely productive outlets for my obsessions and my numbing of pain, which I think everybody has. And so all of the things that have impacted us in those way are largely two edged swords. You know, I think things happen to kids that make them want to be special, make them want to be better, and sometimes that gets channeled into doing things that are ostensibly bad, quote unquote or ostensibly good, quote unquote. I don't want to discount the positive effect my parents have had on my life because I think it has been positive. But unfortunately, I'm also aware that much of my drive is probably unhealthy and probably stems from unhealthy events that, yeah, I don't. I don't really want to talk about.

So this one's related to thinking. I'd like to know what your process is for forming your beliefs. There seem to be a lot of narratives, slash absolutes that people get stuck on in the nutrition world and really miss the quote, it depends, end quote part that you seem to have.

I don't know if I can attribute this to Feynman, but certainly someone I admire has made the point that most facts have a half life. So I think that's kind of the first thing you have to wed yourself to is there's a chance that what I think I know today won't be true tomorrow. And you just have to keep that softly in your mind. You don't have to, like, wake up and berate yourself with that fact every day, but you just gotta softly remind yourself that, look, I think this is true. I may have mentioned this on a podcast once before, but, you know, in mathematics there were proofs, but in biology, there are no proofs. You don't prove anything. An experiment proves nothing. And this something Feynman has stated very eloquently, actually tweeted it, I don't know, a couple months ago. Something to the effect of, like, all we do in science is basically increase the probability that we believe something is actually true. But there's no, there's no definitive proof of anything. I mean, even, frankly, you know, Newtonian physics, which seemed all but said and proved until relativity came along. I mean, it's all probabilistic. So I think if you, if you just show up with the mindset that says, look, we're looking to increase our knowledge by gaining Confidence in the probability that certain things are true or not true. You just get a little bit of the humility that says, yeah, I got to be ready for this to not be true one day. And look, there are things I believed five, six, seven years ago that I still believe are true. And there are things that I believe then that I don't think are true in all cases. I think I've just appreciated more nuance, more exceptions to the rules. And I think the other thing is this is something I think we have the luxury of doing by the nature of the way the practice is set up is it's primarily like a knowledge acquisition grab. So we're kind of not wedding ourselves to the notion that we have to be right. We're wedding ourselves to we want to know the most. And I talked about this, I think, on the podcast with Patrick o' Shaughnessy once. But if you think more about how can I know the most? Rather than how can I be right the most, I think that also takes a little bit of the edge off. My brother actually has a. You know, it's a relatively recent movie. Remember Charlie Wilson's War? There's a scene near the very end when, you know, the Americans are kind of, you know, happy and obviously the Russians have retreated. And now the question is, what should the US Be doing to support Afghanistan? And Gus is making this point, and I'm going to bastardize this. Hopefully we can find the clip and link to it. Do you know what I'm talking about? Where this is telling the story about the boy gets a horse and everyone says, oh, so good for the boy. And Gus goes, it depends. And then the boy's on the horse and he falls off the horse and he breaks his leg. And everyone's like, oh, my God, it's so sad. He's like, eh, we'll see, right? And then there's a war that comes and all the boys have to go off to war except the boy who broke his leg. And all the boys that go off to war died. And everyone's like, oh, it's so great. Blah, blah, blah, we'll see. And the story keeps going. I don't want to say anymore because I've already probably screwed it up 10 ways to Sunday. But I just love the approach of like, eh, we'll see. I mean, we don't really know shit and we certainly don't have a crystal ball. I mean, which is not to say I don't have conviction about certain things. I have conviction about a lot of things. And the challenge of medicine is you do have to make decisions. So you don't always have the luxury of saying, we'll see. We're going to do nothing because there's a risk of doing nothing. And so when I have patients that say, peter, I don't want to do this because you can't give me a 100% chance that it's the right decision, I say that's fine. But I have a much higher belief that if we do nothing, the outcome is this and that's worse on a risk adjusted basis than the outcome of doing something, even though I can't guarantee you it's a problem. Perfect outcome. And that's maybe a bit cumbersome in concept, but I think that's an important thing to keep in mind as the other end of this is you don't want to be paralyzed in your inability to make a decision because of uncertainty. If you need absolute certainty to do everything, you have to play checkers, or chess for that matter. As important as a game as chess is, in the end, it doesn't mirror life because you have complete knowledge at all the time, at every point in the game you have both. Players have complete knowledge. In many ways, poker is a better example of life because you never have complete knowledge. Yes, the probabilities can help you and there is difference between good players and bad players. Those who understand the probabilities, those who don't, those who. But more importantly, it's like, what can people read and not read? And I think the analog in life is not about necessarily reading people, but it's about being able to think about data when there's an income complete set.

I think a couple Feynman quotes. First principle, because you must not fool yourself and you are the easiest person to fool. And then he once said that his definition of science is the belief in the ignorance of experts. And I think sometimes people use that as like a tool to wield against any Sam Tamikis out there who knows everything about, doesn't know everything, but knows a lot. And he can just be like, oh, well, Feynman says you're ignorant. I always turn that one on myself and think like, I'm trying to learn about this stuff. But like, never forget that you're ignorant. There's a lot that you don't know. And one of the things that is apparent to me at least when you think about it, is that as you get older and if you've been in a game where you're trying to learn a lot or you're Trying to grow or better yourself. Think back to five years ago on some topic that you've learned a lot about. So I imagine if you think about lipidology and you think back to five years ago and think, I knew nothing about that subject or something like that, but a part of you five years ago thought, oh, I know way more about. If your ego gets in the way, you think, like, I know way more about this stuff that I'm going to start saying things with platitudes or certitudes about my confidence in what I know. But I do think nutrition just lends itself to. You can be so sure of something because you can never really be proven right or wrong. If you're going to be using, I don't know, epidemiology, it's sort of like you're kind of right, you're kind of wrong, but you can never really be proven wrong necessarily. So it's pretty easy, I think, to go out on a limb, so to speak, and say something's really good or really bad, and you can gather all the information, you can collect all the confirmation bias you want, and it's going to be really hard to disprove your theory. If it disagrees with experiment, it's wrong. Feynman says, it's like, we don't do experiments.

Yeah.

And you need to. We'll probably link, I mean, to Feynman, and his New York Brooklyn accent is unparalleled. We've got a couple questions about your diet. Why did you decide to discontinue your ketogenic diet? What differences in your health and performance have you noticed since? And what does your diet look like these days?

Well, I discontinued a ketogenic diet after three years. In the moment when I discontinued it, it was basically like I was just missing my all singing, all dancing, famous curry stir fry, which was like, probably my staple meal in college and med school and throughout most of life. That was probably my favorite meal. And so on a bed of rice, I would put this huge curry stir fry that had like all of these awesome vegetables and very spicy and blah, blah, blah, blah. But, you know, you couldn't eat that in ketosis even without the rice, because just that volume of vegetables would usually boot you out. And certainly with the rice, you were going to be gone. And I was just kind of like, you know, I just miss this. I just need to start eating this again. Also, I was kind of missing certain fruits. I felt like I was just like, not again. I didn't feel like I needed them from A health wise perspective. I just felt like I just miss them. I enjoy eating these things. I haven't had a banana in three fricking years, except for the odd one or something like that. So it just. For me it was just. That was what it really came down to. And I think the impact of leaving different people have different responses to a ketogenic diet. I think some people at my end of the spectrum respond as well as anyone can respond. I mean, for me it was. It's hard to articulate, right? I mean, on every dimension things just got better. I mean my mental clarity, my resilience, my biomarkers, my performance. Eventually it did take a while. I certainly took a step backwards for the first three months, then regained mostly aerobic function. It was probably 18 months before I surpassed anaerobic function. And I was actually with Steve Finney last week and we were talking about this, that I really regret not taking muscle biopsies throughout that three year journey. I think that kind of could have been quite insightful. But I also know having now put people on ketogenic diets and been around a lot of people on ketogenic diets, that I was about as good a responder as you're going to see. And there are others that have responded as well as me. But there are lots of people who don't respond this well. And so going back to the previous question, I think that's where you have to have a little bit of humility, which is no offense to the keto community out there, who I'm probably pissing off at the moment. Moment. But I'm highly put off by this view that ketosis is for everybody. And if you try a ketogenic diet and it doesn't work for you, well, you screwed it up or something. And it's just like that just strikes me as patently false. So anyway, I don't know if I answered the question. Was the question okay? Oh, then the other question is what do I do now? Now I mostly vacillate between time restricted feeding and non time restricted feeding with a much simpler set of principles on how I eat, which is just try not to eat junk. So I don't really restrict my carbohydrates deliberately at all anymore, which I know is going to sound crazy to people listening to this, but I just restrict bad carbohydrates and as a general rule if it comes in a package, it shouldn't be eaten. So like the wens, like there's no role for weins in the diet, right?

Graham, I'm sure there's a wens tree somewhere. These are our paleo ancestors. Were you there? Were you there? Are you sure there wasn't a tree?

You know, it's a very good point. I wasn't there. It's quite possible that Weins grew on trees with graham crackers, my favorite. My go to starches. You know, I definitely like potatoes and I definitely like rice and I probably will, you know, if there's seven days in a week, four of them, I'll be eating those with at least one of my meals. So yesterday I usually am not eating breakfast still. So yesterday when I woke up, you know, did my morning routine, rode the peloton for 45 minutes, had, you know, made a. My coffee, my special fancy coffee after that, and putzed around and like worked and you know, whatever, did all my, you know, saw patients, did this, that and the other thing, came back to my apartment at 2, still hadn't eaten, and then made a shake. So I make this shake called that I call the Peter Kaufman, which I wrote about on the blog like six years ago, which is a little bit of heavy cream, almond milk, frozen strawberries, spoon of almond butter, and then a youcan protein, chocolate protein with a ton of ice. So it makes. We're going to have one right after this, by the way, in about five minutes. So salivating for the Peter Kaufman. And so that's a pretty high fat shake where the only carb you're getting is the superstarch, which basically doesn't act like a carb. You obviously get some in the almond butter and there's virtually none in the frozen strawberries. And then that evening, yesterday evening, so I didn't eat anything else the rest of the day. Obviously just, you know, had like water or something like that. And then in the evening I went out for dinner with a friend and we went to a Greek place and you know, I had a smoked salmon appetizer. It did come with like little pita chip breads which I didn't eat. Although in truth I will often eat those because I freaking love them. But just yesterday I didn't think feel like eating them. And then I got a lamb entree that came with some potatoes, these lemon potatoes that these guys make that are ridiculous, you know, no dessert. Came home, had some tea, that was it. So when I look at my CGM from yesterday, my highest glucose was about two hours after dinner, maybe an hour after dinner, but it was about 117 milligrams per deciliter was my peak glucose. Yesterday. And the other thing I really pay close attention to is what was my peak nighttime glucose. So by the time I went to bed, it was down to 90. And you know, I think my peak, my peak Nighttime yesterday was 95, which makes me really happy because I almost always see my highest glucoses at night. They're almost always, I think, in response to cortisol. So today we'll have one of those shakes for lunch, maybe we'll go work out, then we'll shake and then for dinner, I don't know what we'll do, but it'll be basically the same sort of thing. It'll probably be, oh, I also had a big salad yesterday. I forgot to mention that. The smoked salmon, the big ass Greek salad in a bowl the size of my head and then the lamb with the potatoes. So I'm kind of a boring eater actually, which is I like to have lots of vegetables, including salad. I usually rotate lamb, beef, fish, and then at least half the time, if not more, maybe a bit of potato or rice.

I think you might have tipped your hand when you did a regimented three year, pretty much all on ketogenic diet. And what kicked you out of a ketogenic diet was your longing for vegetables and fruit, more or less. And then on the exercise side, not doing the muscle biopsies or something like that. So I think most people might be going for the chocolate cake. Although you did have one.

I had that one day, yeah. Where I had six desserts in one sitting. You know, I'm sure I'll go anytime I'm with my like keto friends. Like last week when I was up with Steve Phinney and a whole bunch of the people from Virta Health, I swear I was like, that's it, man. I'm going back on keto. You know, I'm going to go back on a ketogenic diet. And then I got home and I was like, nah, I don't feel like it's just. And honestly, part of it, this is a total cop out, but part of it is just like it's a pain in the ass with kids. I don't want to get into weird stuff with my kids again because I remember when I was on ketogenic, my daughter was always asking me why I didn't eat this, why I didn't eat that. And I feel like, and again, I'm not knocking a ketogenic diet and I think I could do it and do it in a responsible, sustainable way as far as my kids. But I like now Talking to my only. My daughter, my son. So obviously we don't talk about this stuff yet. They're not old enough. But with Olivia, there's definitely a lot of talk of, like, the other day, like, you know, it was her birthday and there was a ton of ice cream left in the fridge, and she came home from school and she's like, daddy, can I have a bowl of ice cream? And I was like, hell no, you can't have a bowl of ice cream. What the hell are you talking about? She's like, well, mommy lets me. And I was like, I'm pretty sure mommy doesn't let you have ice cream before dinner. And don't you get how bad that stuff is? Like, you get to have that once in a while as a treat. But, like, that didn't grow on a tree. That didn't come out of, like, that's fake food. Right. And. And so it's. There's still the opportunity to talk about that. And. And, you know, I like that they're seeing me eat a broader array of food now than I would be if I were on a ketogenic diet. Because when I was on a ketogenic diet, the other thing is I was on such a high calorie ketogenic diet that I had to eat so much weird stuff. Like I had to basically eat a tub of sour cream every day just to get my 4,500 calories that I needed.

What was your ratio of a ketogenic diet? A lot. But for epileptic.

Yeah, I was.

They talk about carbs to pro.

Yeah. So I did it in total percent. I did it as a percent of total calories.

And I was fat to protein and carbs.

Yeah. I was about 90% fat, about 7% protein, 3% carbohydrate. And the reason that my percents were so high in fat is that my total caloric intake was probably 44 to 4,500 calories a day. But I was exercising like crazy.

Yeah. I always. I marvel at what a ketogenic diet sort of technically is. I mean, if you're looking at like the Hopkins ketogenic diet, where it's 4 to 1, fat to protein and carbs in terms of, I think by weight. So if you're eating 100 grams of protein and carbs, you're eating 400 grams of fat, which is 3,600 calories. So you're looking at a 4,000 calorie diet probably close to maybe what you're doing.

Right.

75 grams of protein, maybe 25 carbs, maybe lower. And you're doing that and you don't realize, like, that does take effort. It's not just like, I'm just gonna eat some meat and I'm gonna eat some vegetables and some nuts and seeds.

It's huge effort. Unless you have the luxury of, you know, a chef or prepared meals. Like, I don't know if Quest is doing it anymore, but they were at one point doing like pre made 2 to 1, 3 to 1, 4 to 1 keto meals. And I think they were doing it with the Charlie foundation actually for the kids with epilepsy. And I ate a bunch of those like just as trying them out. And I mean, they were great. I could mainline those things if someone were like feeding me those all day. Yeah, I could go back on ketosis with. But maybe I'm just too lazy.

I don't know.

I know you said that there were questions on stuff that we've already either done a podcast on or will be doing a podcast on. So we'll punt on those. Do you want to. What. What are those topics?

So we have a lot of topics around statins.

What are those?

So when would you use them?

I meant what are statins?

Never heard of them.

Never heard of them. I don't know what that is.

You were talking about Tylenol before. I was drawing a blank too. Smart drugs and supplements. So drugs and supplements for cognition, also smart drugs, also drugs and supplements for performance, heat and cold therapy. Really interesting topic. I'm sure we'll dig into that too. Hrt, I believe hrt at least estrogen and hormone replacement therapy in women was on your poll. It was either HRT or LP for the first topic. So I'm sure that might get thrown back in.

That's right. Yeah. And I think LP1 hands down, like 80, 20. But we'll definitely be taught. We'll definitely do a dedicated thing on estrogen and hrt.

Okay. Autophagy, apoe, which we got into a little bit, and depression, sort of what genetic effects, environmental effects and how do you handle it?

So I'm going to be. I reached out to one of my best friends who's a brilliant psychiatrist, Paul Conti, and actually just a couple days ago and said, hey, let's do a podcast. And I want to talk all about depression, everything about it, environmental triggers, the genetics of it, treatment strategies, all that stuff. So Paul is totally game to do that. So we're going to do that podcast this summer. We're going to be talking to Rhonda Patrick, soon we're going to get. I'm sure Rhonda is just. We're going to have so many great things to talk about, so I'm sure a lot of the heat and cold smart drug stuff will probably come up there. We're going to do one with Dom d' Agostino soon, and that's going to get into a lot of ketosis stuff. We've already done a great one with Ron Krause and that's going to touch on all of the statin stuff.

Autophagy.

Yeah, we'll probably have to. Well, we actually did. We does the Sabatini one. No. But we've got the other MIT ones that get into.

Oh, yeah. Greg and Monther at mit.

So I think we've got into that a little bit. Yeah. So we've got some great stuff there. We do need to probably do a dedicated APOE one, and I think we'll definitely get into exercise. In fact, I'm going to be speaking with Mark and Chris Bell this summer. It's odd because we don't know when this is actually going to be released, so I guess we're going to have to release this one early so that what I'm saying makes sense. So with Mark and Chris Bell, I'm sure we'll have plenty of chance to talk about exercise, especially around. Around strength training, hypertrophy and things like that. So I think we got it. Is there any other question that we need to get at before we either go make a shake or go.

No, I think that's good. I think hopefully we'll do more of these so we can reload and do some more.

All right, man. Well, thank you for compiling all of these.

My pleasure.

I loved being able to not have to pay attention to any of those questions on Twitter, knowing that you were. You were. You were codifying.

Oh, that's one quick thing. It's funny because I think everybody goes through this where they think, I'm getting off of social media, I'm getting off of Twitter, I'm getting off of Facebook. It's doing me no good. I need to just like the first question, I need to get back out into nature. I think this is doing more harm than good and distraction. And then Peter says, you're going to need to get on this Twitter and start handling these questions and the Twitter wars and things like that. But it really was a pleasure. Like, all the questions that you got were. I don't want to say all of them, but most of them at least were excellent. And I'm looking at the master list and there is stuff. There's NAD and nicotinamide, riboside and terastilbene.

Oh God, we've got all that stuff.

So nad, nad.

So you've shielded me from most of these questions?

Mostly, yes.

All right, well, maybe we'll figure out, take a look at what you've got here versus there and we can decide if this is something we should be doing quarterly or what's the frequency with which we could do AMAs. I mean, I think we got a lot of sort of nothing burger questions out of the way that probably don't come up again, like race car driving questions and childhood questions. But you know, we'll go from there. All right, man. Well, listen, thank you very much and thank you everybody for submitting your questions. I hope that this format made sense and wasn't a complete waste of time. You can find all of this information and more@peterattiamd.com podcast there you'll find the show notes, readings and links related to this episode. You can also find my blog and the Nerd safari@peterattiamd.com what's a nerd Safari, you ask? Just click on the link at the top of the site to learn more. Maybe the simplest thing to do is to sign up for my subjectively non lame once a week email where I'll update you on what I've been up to, the most interesting papers I've read, and all things related to longevity, science, performance, sleep, etc. On social you can find me on Twitter, Instagram and Facebook, all with the id PeterAttiyamd. But usually Twitter is the best way to reach me to share your questions and comments. Now for the obligatory disclaimer. This podcast is for general informational purposes only and does not constitute the practice of medicine, nursing or other professional healthcare services, including the giving of medical advice. And note no doctor patient relationship is formed. The use of this information and the materials linked to the podcast is at the user's own risk. The content of this podcast is not intended to be a substitute for professional medical advice, diagnoses or treatment. Users should not disregard or delay in obtaining medical advice for any medical condition they have, and should seek the assistance of their healthcare professionals for any such conditions. Lastly, and perhaps most importantly, I take conflicts of interest very seriously. For all of my disclosures, the companies I invest in and or advise, please visit peteratiamd. Com about.