#145 - AMA #19: Deep dive on Zone 2 training, magnesium supplementation, and how to engage with your doctor

Foreign. Hey everyone, welcome to a Sneak Peek, Ask Me Anything or AMA episode of the Drive podcast. I'm your host, Peter Attia. At the end of this short episode, I'll explain how you can access the AMA episodes in full, along with a ton of other membership benefits we've created. Or you can learn more now by going to Peteratti md.com subscribe so without further delay, here's today's sneak peek of the Ask Me Anything episode. Welcome to Ask Me Anything. I'm once again joined by my head of research, Bob Kaplan in this episode, AKA Ron Tugnut. In today's episode, we go really deep on Zone two. We touch on exercise a little bit more broadly than that, and we get into a few other tangents outside of Zone two, like what is FTP, Zone five, you know, some of the anaerobic stuff. But mostly this is a super deep dive into Zone two from a practical level. So if you've heard the Inigo San Milan podcast, you'll have obviously an understanding of what that is. If not, don't worry because we revisit it. But more importantly, I think we kind of get into the how to do it, what's the dose, what type of exercise, what type of machines, the frequency, what if your numbers look like this, you know, all of that kind of stuff. So I hope by the end of this episode you'll really understand how to bring Zone two in as one of the four pillars to your exercise program. The other two things we get into in this episode are a kind of lowdown on magnesium. So we had a great question about, hey, Peter keeps talking about this type of magnesium, that type of magnesium, this type of magnesium. Can you give us the skinny on that? And so we get into that and then we close it out with, with a short discussion on the how do you actually talk to your doctor about some of the stuff that we're getting into here? A couple of weeks ago, actually a couple months ago now, we had a newsletter that talked about early screening or more aggressive screening on colonoscopy, which is a sort of point of view that I have. And there were many questions from listeners saying, hey look, sure, that'd be one thing, if you were my doctor, we could have this discussion. But having this discussion with my doctor is actually much more difficult. And so I try to offer as many insights as I can into how one would go about doing that without being off putting and obviously trying to get the best care you can. So without further delay, I hope you will enjoy. Hey Peter, how you Doing Ron Tugnut, how are you?

The one and only. I'm doing pretty well.

I feel like our AMAs have turned into basically a game of hockey obscurity where every time we meet on video, you've got a different 1980s/90s goalie as your ID.

That's right. Growing up, just loved the Bruins and hated every other team. But I had a lot of respect for Ron Tugnut. Boston Bruins saved 70 shots in a 33 tie. It's just absolutely unbelievable. It's on YouTube. Check it out. Just some of the saves that he was making was just unreal. It's a great game.

Yeah. Mr. Tugnut actually is from my home borough of Scarborough, Ontario, the little crappy outpost of Toronto.

I remember that we've got a nice Easter egg if anybody cares to look in the Studying Studies series. If you go to. I think it's Studying Studies part two and I think it's Figure two. It's about chimney sweeps. Check out that figure caption. It's pretty impressive.

I forgot about that. Thanks for reminding me.

Yeah, you approved it, so it's there.

What do we have on the docket today for Ask Me Anything?

We have a lot of questions related to exercise in Zone two. We also have a few questions around magnesium. And then we got a lot of follow up questions on a couple of weekly emails which were. I think the earlier one was how to find a good doctor and the questions that you should ask of a doctor. And then we also had a weekly email on colorectal cancer and colonoscopy and a lot of questions that you should ask your GI doc before getting a colonoscopy. And we had a lot of questions around how should I approach my doctor with these questions? Is there a way to do that that's most effective?

If we can get through all of that in one episode, I'll be delighted. But let's see how far we can.

Absolutely. Okay. Zone two in exercise. Questions. First type of exercise. One of the questions we received is what is the best device to buy if you want to do Zone two in your home? Rower, stationary bike or treadmill Bob.

Or should I say Ron? May I take a step back from this before answering it and create a bit of a broader context? If there's a listener who's not familiar with exactly what Zone two is, I'll allow it.

I think it'll be helpful.

Thank you. As you know, in our practice we have kind of a framework for how we think about exercise and it has four components. Those components are Stability, strength, aerobic efficiency and anaerobic performance. Now, I will focus on one of those today. I just want people to understand that when we talk about Zone 2, it doesn't mean at the exclusion of these other things, stability, strength and the anaerobic piece, but it is the way in which we think through the aerobic piece. So you don't want a table that stands on three legs or two legs, or, God forbid, one leg, any more than you want a root canal. And therefore one has to be very clear that when you think about Zone two, you understand that it is but one component. In subsequent episodes of both the podcast and AMAs, we'll get much deeper into these other things. When you understand that, you understand. Okay, well, Zone two, it's got a very clear definition. And this was covered in a previous podcast with Inigo San Milan. I don't remember what number that is, but obviously we'll link to it. 85. So it is defined as basically your highest metabolic output, the highest amount of work that you can sustain while keeping your lactate level below 2 millimole or 2 moles per liter. So what does that mean in English? To understand that, you have to think about what's happening biochemically as you exercise or frankly, do anything. The process of respiration, which is central to our existence is the process of using substrate. And for the purpose of this discussion, let's just think about glucose and fatty acids and oxygen to make ATP and carbon dioxide. So let's just restate that. We use glucose, we use fatty acids, we use oxygen, we undergo a chemical process. So we take the chemical energy that is stored in the bonds of those molecules, we turn that into electrical energy. People have heard of something called the electron transport chain, which is the bulk of where that takes place. And then it gets turned back into chemical energy as we borrow from that energy to make ATP. And then ATP becomes our currency for how we do everything. And just again, to put this in perspective, any interruption in that system is fatal. So when you think about a toxin like cyanide, why does a microscopic dose of cyanide kill somebody instantly? It's because it actually stops that process. Now, people may already appreciate that there are a couple of different ways that we can go about making ATP. And it basically comes down to how quickly the body is asking for it. So the first step, and let's just limit ourselves to the discussion of glucose to make this really simple, the first step is turning glucose, which has it's a six carbon ring, into two smaller molecules that are each made up of three carbons called pyruvate. And that process doesn't yield a whole heck of a lot of ATP. It yields a little bit, costs a bit, makes a bit. But when you stop there, the body kind of has a choice. And the choice is, do I continue this process outside of the mitochondria, where I make another byproduct called lactate and I can generate a little bit more ATP by the way, or do I take that pyruvate and shuttle it into the mitochondria and undergo a separate chemical pathway and a separate process called the Krebs cycle, where I can make many, many more ATPs. So we'll obviously link to sort of figures that make this much more clear graphically. But if you need to make ATP really, really quickly, you'll take that former pathway and make lactate, because you don't need oxygen to do it. So you're not limited by the amount of oxygen that is being taken up by the muscle. If you have time on your hands, you'll take the latter pathway, which means you will utilize oxygen and actually take that substrate into the mitochondria and you will be able to make tons of ATP. Now, all people are not created equal, both genetically, but more importantly through training. And one of the biggest things that differentiates the highly trained from the untrained, the metabolically fit from the metabolically unfit, the flexible from the inflexible, is that ability to, under a greater and greater array of metabolic demands, make that input of substrate into the mitochondria. So mitochondrial health then can be somewhat estimated and proxied by the ability a person has to do this. So how would you measure this? I mean, shy of doing muscle biopsies and things, which obviously we're not going to do, how can we get an estimation of this? And it turns out one of the most valuable ways to do this is to measure lactate levels, because we can measure this. This lactate, if you start producing too much of it, will actually escape the muscle and get into your circulation. And you can measure it very easily with a finger prick, just as you would measure glucose or ketones or some other metabolite. A healthy person, when they're sitting there at rest, has a lactate level of about 1 millimole. If they get up and move about their day and walk around and have breakfast and watch TV and get in the car or do whatever they're doing, their lactate really shouldn't be changing. They're actually demanding more ATP than if they were sleeping. But a reasonably metabolically flexible person and healthy person, those activities I just described shouldn't at all be pushing you to generate higher levels of lactate. So, in other words, you're not accumulating lactate. Now, what happens if we ask you to start doing something a little more strenuous? At some point, you're going to start generating lactate. It doesn't matter how fit a person is. If you push the fittest person on the planet, at some point they're going to have to start generating lactate, because you're basically saying, I need you to make energy or ATP faster than you're able to deliver oxygen to your muscles. And at some point they can't clear that lactate. So at some point, the lactate begins to accumulate in excess of what is cleared. And we can measure that. Now, it's a bit more complicated because the organ that is primarily responsible for clearing lactate is the liver, and it does so via gluconeogenesis, and that takes longer, so there's a big time lag there. The other thing is different people have different amounts at which they clear lactate from the cell. So everything I'm describing is taking place in the cytoplasm of the cell. It still has to escape the cell to get into the circulation, and it does so via transporters called mcts. So different people can have different levels of MCT expression. But if you put that aside for a moment, it's crystal clear that the fitter a person is, the healthier a person is, the more work they can do with less lactate. And therefore, for a given individual, we use this metric of Zone 2 as a place to say, how metabolically healthy are you? How good are your mitochondria? And that means how much work can be done while you keep your lactate right at about 2 millimole, we kind of use a slight range. We'd say about 1.7 to 2 millimol. So how does one do this? So if I'm walking down the street and I run into you and I say, hey, Bob, what's your Zone two? And we were both in the know on this. You could literally spit out a metric. You could say, oh, my. Zone two is 200 watts. That would assume that you're riding a bike, and that would mean you could hold 200 watts for a very long period of time, because you're never really going above 2 millimole. And 2 millimole is a very, very sustainable level of lactate production. People have probably heard the term lactate threshold. This is well below lactate threshold. Lactate thresholds for most people kind of in the 4 millimole area and at lactate threshold an athlete is really only able to hold that pace for depending on their level of fitness, we're talking tens of minutes if not less. And obviously peak output is gonna produce lactates easily over 10 and in some cases over 20. Those are efforts that can be sustained for seconds. Sort of all out 2 minute effort might produce that in a very fit individual, but Zone two is functionally thought of as your all day pace, but there is an enormous variability between what some can do and what can't. In the podcast with Inigo, we discuss one of the studies that he did, I believe with George Brooks, where they compare people with type 2 diabetes to people who are normal, fit people, to world class people, world class athletes, I believe cyclists. And the difference in the zone 2, meaning the amount of power that they could put out on a bicycle while keeping lactate at 2 was staggering. Especially once you normalize for weight, which is really the way you want to normalize these things is not just how many watts, but how many watts per kilo. So I know that was a bit maybe more information than people wanted up front, but I don't think you can understand everything you're probably going to want to ask me without that. So now your question, if I recall, was if you want to do your Zone two training at home, what's the best type of device to do it on? Thank you for listening to today's Sneak Peek AMA episode of the Drive. If you're interested in hearing the complete version of this ama, you'll want to become a member. We created the Membership program to bring you more in depth exclusive content without relying on paid ads. Membership benefits are many and beyond the complete episodes of the AMA each month. They include the ridiculously comprehensive podcast show notes that detail every topic, paper, person and thing we discuss on each episode of the Drive. 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