#261 ‒ Training for The Centenarian Decathlon: zone 2, VO2 max, stability, and strength | Peter Attia, M.D.

Hey everyone. Welcome to the Drive Podcast. I'm your host, Peter Attia. This podcast, my website and my weekly newsletter all focus on the goal of translating the science of longevity into something accessible for everyone. Our goal is to provide the best content in health and wellness, full stop, and we've assembled a great team of analysts to make this happen. If you enjoy this podcast, we've created a membership program that brings you far more in depth content. If you want to take your knowledge of this space to the next level, at the end of this episode, I'll explain what those benefits are. Or if you want to learn more now, head over to peterattiamd.com subscribe now. Without further delay, here's today's episode. Welcome to a special episode of the Drive. For this week's episode, we're going to release the live AMA that we recorded celebrating the release of Outlive, which was recorded in April. We received a good bit of feedback from those who were invited and able to attend this episode live, so we decided to make it more widely available. Our AMA is of course, are typically reserved only for our subscribers, so if you're not a subscriber, this might give you a bit of an idea what our AMAs are like. Although this is not the typical format, usually our AMAs go a little bit deeper into content than this one, but nevertheless, hopefully this gives you a sense of what we're up to. In this episode, we really focus the entire conversation around the Centenarian Decathlon. We speak about the events in my centenarian decathlon and how I decided on them, and how I work with patients to create their own list. We then talk about how people can know if they're on track for their centenarian decathlon across a variety of ages and the various fitness tests that can help determine that. We focus the rest of the discussion around training for the centenarian decathlon, including what that training should look like, whether you're older, younger, new to exercise, or a veteran. And we talk about some questions that came up around zone 2 and VO2 max training. So without further delay, I hope you enjoy this special episode of the Drive.

Never done a live event, Never done a live ama. Everything has been recorded. So how you feel Ready? You feel like there's more pressure on this? Because there is. You can't screw up. Everything you say is officially written in stone. Yeah, that's good. We'll see how it goes. So what we're doing tonight today, depending on where you're at, is kind of an ama, that's all focused on one thing, which is the Centenarian Decathlon. And so what we did is for everyone who pre ordered they could sign up for the event, they submitted a bunch of questions. We went through. I mean, there was thousands of questions. So right off the bat, we'll apologize to anybody who we can't answer the question. But we tried to group them together, kind of organize them a bit really to try and get through as much as we can. So if anyone has heard our AMAs before, they'll probably know. Sometimes we can go into a little bit of detail, and sometimes one question can take a while. But the goal for this one is more of that rapid fire. Let's see how many we can get out. And it should be good. So anything you want to add or say before we get rolling?

No, but feel free to interrupt me if I'm being too long winded.

All right. We'll just point at the watch and say we got to speed it up. So I think what would be helpful is because we did get a lot of questions around, hey, what's the best thing you can do for longevity? Like, if there's only one thing, you know, you have five tactics in the toolkit. But if there's one thing people should focus on, what would that be? And maybe it'd be worth just kind of giving a little piece on that. Just as we set the stage on why we decided to focus on the Centenarian Decathlon and kind of why you think that's so important for people's longevity journey.

Yeah, I mean, look, it's an impossible question to answer because if you got a person who's sleeping four hours a night, if you don't fix that, nothing else will matter. If you have a person who's malnourished, you sort of have to address these issues. But generally speaking, if everything in your Life is a 6 or 7 out of 10, taking your exercise to a 10 out of 10 is going to have a greater impact on both the length and quality of your life than any of the other domains that I can think of. Perhaps with the exception of emotional health, that's one that can be such a binary thing. If you take a person, for example, like me, where that house is not in order until that's addressed, all the exercise in the world wouldn't fix that either. So it's a tough question. I get asked that question all the time. I wish I had a slick answer for it, but that's really the best I can say.

Yeah, if anyone's read the book and has a really quick 30 second answer they want to email to us that Peter can steal. Feel free to do that because we'll take it. So I think it'd be helpful maybe. Let's just quickly define centenarian decathlon, marginal decade, two terms that we use quite a bit. Obviously people will have read the book, but I think it's still good to just get a quick definition of that because it will set the stone for everything we're going to cover.

Yeah, marginal decade is the last decade of your life. So everyone will have a marginal decade. Most people certainly don't know the day they enter it. Sometimes you know, when you're in it, especially if you're nearing the end of it, a person probably has a sense of that appreciation. But it is an important model because I think that the marginal decade for most people is really a period of poor life quality. Physical health has usually declined significantly. Cognitive health potentially has declined as well. As I sort of observed many people in their marginal decades, including people I've been close to, I noticed that there can be a great sense of withdrawal because of these things. Right. You're not participating in life. So the idea here is quite simple, which is if you plan to have a remarkable marginal decade, by definition, it means that all the decades that came before it also had to be pretty remarkable. And the analogy I use in the book is that of an archer, probably because that's what I am. But if you really want to be proficient at 50 yards with a bow and arrow, practice at 100. And you'll be amazed at how simple 50 becomes. And 60 and 70 and 80. It's a very nonlinear relationship in terms of accuracy. With a bow and arrow, the centenarian decathlon becomes the scaffolding upon which I actually think of this. So this again came from an idea or an observation I suppose I had in my own life, which was from age 13 to about 42. I was constantly involved in something very specific that I was training for. So I never exercised. I trained. I trained for boxing, I trained for cycling, I trained for swimming. I had competitions, I had meets. And everything I did vis a vis exercise was in service of a goal. And that made it very easy. There was real specificity to what I did. And then when I sort of hung up my bike, I realized, oh my God, like I don't know what I'm doing. I mean, I'm still exercising, but it didn't feel like it had a purpose. And I sort of realized that's actually how most people exercise. And when compared to the alternative, which is not exercising, that's okay. But I realized as I thought more about this marginal decade, I needed to be very specific in my training to make sure I didn't arrive there and sort of leave it to chance. Would I be strong enough, healthy enough, have enough balance, all of those things. And so what I realized is I had to, you know, to borrow the phrase from Annie Duke, I had to back cast from that marginal decade around a set of very specific events. And that set of events we would call the centenarian decathlon. And everybody's going to pick different events. These can be activities of daily living. These could be very specific recreational activities. I think it's a good idea to have both in there. And the more specifically you train for those, the more directed your training is.

And I think what would be helpful right now is I know you have that list right next to you is maybe just reading through your list and again, as you kind of stated, your list doesn't mean it has to be everyone else's list. But a lot of times I think when there's newer concepts or people are trying to figure out how this works, it's helpful to hear an example. So do you kind of want to just burn through your list and let people know how you're thinking about this in your life?

I will say this. It's organized in a way that's a bit confusing because in my mind I'm constantly thinking, okay, mobility and strength matter. Aerobic capacity matters. So sort of aerobic efficiency matters, peak aerobic performance matters. I'm in the back of my mind thinking I have to make sure I can do all of those things well. And then some of my centenarian decathlon Olympics are like exercises or metrics or feats and others are activities. So I'll try to add a bit of color here real quick.

You kind of mentioned your four pillars of exercise, but people also known by different things. Which is zone 2 maybe, or VO2 max. So do you just kind of want to explain?

Yeah. So when I talk about aerobic efficiency, that's zone 2. When I talk about peak aerobic output, that's VO2 max. Strength, stability. In with stability is mobility, balance, things like that. Okay, so in no particular order, pick up a 30 pound child from a squatted position or from a crib. Those are two very difficult positions. So that requires strength, stability, mobility. Get up off the floor with one point of support. That's stability and strength. Place a 30 lb suitcase overhead strength. Also mobility, dead hang for 30 seconds. Strength and stability. Farmer walk for one minute with 25% of body weight in each hand. So again, it's something that today I could do for a day that's really pushing the bounds of what I would want to be able to do in my 80s. For example, strength and anaerobic pull or push a weighted sled 100ft with. And I've put in here kind of a metric of resistance. Again, what is that really all about? This is kind of one of those things if you're in a dangerous situation, a spouse has fallen, you have to pull somebody out of the way or something like that. Walk up and down stairs with feet pointed perfectly forward. So if your feet are pointed perfectly forward as you're walking up and down flights of stairs, it means you still have the ankle mobility to do that. So you can get an angle angle between your foot and your tibia, your shin into an acute angle as opposed to having to turn your feet outward. Single leg, stand with eyes open for 30 seconds with eyes closed for 15 seconds. Single leg, get up without support. So like getting up off a seat, for example. Hex bar. Deadlift my body weight for 5 reps. Again, pretty aggressive. Not now. A dumbbell lunge in perfect form with 15% of my body weight in each hand for 10 reps. Cover three miles in one hour by foot. So again, that's 20 minute mile is pretty slow. But if you think about being able to do that in the last decade of your life, carry 20 pounds up four flights of stairs, produce a VO2 max above 30 milliliters per minute per kilogram. And if you can do that, that basically buys you a whole bunch of activities. That means you could walk up a 6% grade at 3 miles an hour for a period of time, not necessarily for an hour, but perhaps for 20, 15 minutes. Tread water for 10 minutes. Not that I have a plan to, but you and you think about what's implied. Like, that's a very functionally aerobic thing to do. Scale a ledge at shoulder height or pull myself out of a pool onto A deck 12 inches above the water surface. Single leg glute bridge, 15 reps without loading my lumbar spine and do a plank in perfect form with scapula retracted. No hip sag for one minute. So I have several of these lists. There are things that I would add to this that are, you know, or I have on a different list that get more into recreational activities. I do want to be able to pull a 50 pound, bow, back, a compound bow, that's 50 pounds. And a compound bow, of course, lets off as you get further, but you still have to be able to pull £50 at the outset.

So I think it's helpful for people because if you think about the list, you made very specific things, but you kind of hinted at there's a reason behind everything. The dumbbell being able to lift it is grandkids, great grandkids, you want to be able to play with them. Being able to get off the ground is you want to be able to live by yourself or with a spouse and be able to fully move, not worry about falling. And so if anyone's having trouble kind of thinking about how they do it, it's sometimes helpful to just take a step back and be like, do you want to live in a city area where you can walk to get groceries and bring them back? And then you can get specific from there, too. So for anyone who's kind of thinking, okay, what specifically should they think about for that? Always feel free to take a step back and then get detailed going forward. Now, you mentioned earlier kind of emotional health, there wasn't anything on there on your list as it relates to that, and we did get a few questions on that. And also, you know, you kind of talked about how physical and cognitive, as you get older, is always going to decline, but emotional health on the other end, that's the only piece of health span that can actually go up. And so is it purposeful? You don't have that on your centenarian decathlon list?

Yeah, the centenarian decathlon is focusing purely on that physical piece that is invariably going to decline. So it doesn't really get into the cognitive or, as you said, the emotional part, which, if we're really doing that right, should be getting better as we age.

When you talk to your patients about this, because I know you work with every patient, you want them to be able to create this list and kind of anchor back to it, because like you said, is you're not training for a marathon, you're not training for a triathlon. You're really training for this. What advice, what encouragement do you give them as they're starting to kind of think through, okay, how do I create this list? How do I start to build this process in my mind?

We've gone through several iterations on this. Initially, we asked patients to do what I did, which is just sit down and come up with the list that didn't produce as much fruit, perhaps because people weren't putting as Much thought into it as I was, you know, it just wasn't something they were spending all of their time thinking about. So what we do now is we give them a list of about 50 items. About half of them are activities of daily living. About half of them are sort of feats of fitness or strength. And we say pick 10. And we've gone through multiple iterations of this. We used to say, pick as many as you want. That turned out to be, so now it's like pick 10. So you have to really think about this. You have to prioritize what are the 10 most important things to you on this list? And then we ask the question, okay, to do those things, do you know what is required, do you know what's required to pick up a 30 pound child off the ground? What type of stability is required? What type of strength is required? And how much will that require you to be able to do today? Based on the extrapolation of how much those each of those parameters declines.

And one of the questions we got come through a ton was those are the things you want to do at a hundred.

To be clear, I don't expect to live to 100. You know, if you look at my wall chart, it says 88. So call it in. My 80s is probably, you know, where.

I hope to be in your marginal decade.

In my marginal decade, yeah.

So how are you thinking about, okay, so if in your marginal decade you want to be able to do that, you know, there's people who are listening who are going to be in their 20s, 30s, 40s, 50s, 60s, 70, 80s. The people who are on the younger spectrum of that were kind of wondering, you can do all those right now, easy, all day, every day. So how do you think about how much you should be able to do in your 30s or 40s or 50s? How do you talk to patients about how they back cast and figure out, okay, my goal at 40 should be X, to be Y at 80.

We have a pretty good sense of how major parameters like strength and VO2 max decline with age. And so even though I can do everything on that list blindfolded, it's going to take a lot of work to make sure that my VO2 max is 30 to 32 mils per minute per kilogram in 30 to 40 years, especially if it's closer to 40 years. And truthfully, like right now, my VO2 max is not what I'd like it to be. It's probably in the mid-50s, which is again, fine for somebody my age, but I really would Like a bigger margin of error and maybe want it to be mid to high 50s as opposed to low to mid-50s. So if you're 30, if you're 20 years younger than me, the bar is even higher. So paradoxically, the youngest people aren't necessarily in the best shape here on a relative basis. They might be in absolute terms, but they have longer to maintain that and therefore they have to be starting from a higher place.

You mentioned VO2 Max there. Do you maybe want to talk about a few metrics or tests people could do so they can understand where they're at currently? From a cardio perspective and let's say.

A strength perspective, VO2 max is. I don't know that it's necessarily the single best metric of cardiorespiratory fitness, but it's certainly the one that's been studied the most. And it's obviously the one that for which we have the most data. It's also one that you can go out and get done on your own. It's a hundred dollar test, maybe $150 test. You can go and find any in most cities they would be able to do this for you. There are also free versions. You can estimate it. You could run a Cooper's test or various versions of these tests which we've talked about elsewhere. And you can just look that up if you want to run, know how to do that protocol. So you don't need to even spend a dollar to estimate your VO2 max if you're willing to go down to a track and run a mile or something. So the question then becomes, what are some other metrics that go with it? Well, I mean, certainly strength metrics matter. We've talked about some of those things. A great metric for both upper body strength and grip strength and a bit of stamina to boot is a farmer carry. And so for men, we'd like to say a guy in his 40s should be able to carry his body weight for a minute. So half his body weight in each hand.

Do you maybe want to explain what a farmer carry is for people who aren't familiar?

Yeah, it's literally just carrying and walking. So if A person weighs 180 pounds, can they put 90 pounds in each hand and walk for a minute? For a woman who's 40, we would want to see that at about 75% of her weight. So just do the math and adjust accordingly. I've talked about the dead hang, that's another great one. For grip strength, again, we have sort of metrics that we would look at, we would say a man in his 40s. We'd want to see two minutes of dead hang for a woman, a minute and a half. And then, of course, that gets discounted by roughly 10 to 15 seconds per decade as you go from 40 to 50, etc. There are other, you know, great examples of strength. A wall sit, for example. Can you do a wall sit for two minutes? So you're sitting with your back against the wall, your thighs are parallel to the ground, you're not using your hands. And basically, this is a one way to test leg strength. There are better ways to do it. We typically do this in a more free form where we have people do. We have people do a squat, air squat, where they're hovering but not using their back for support. So now it's a little more stressful because you're not just using your legs, but you have to stabilize. Whereas on the wall sit, you get all the stabilization for free because you're pushing back into the wall. So, you know, there are no shortage of ways to do this kind of thing, and probably beyond the scope of our discussion now, to go through all the different ways. Zone two, of course, is another really important thing to do. So there's the technical way. It's defined based on lactate production. But again, the simplest way for most people is the. Is the RPE way, right? Is. Is zone 2 is that threshold where you go from being able to speak while you're exercising, but being uncomfortable to not being able to speak. And where most people cross that threshold is where you will now start to net. Accumulate lactate with your activity. And so figuring out and demonstrating that you can generate more and more work at that level, whether it be wattage or speed or whatever your metric you're using, that becomes also just an enormous way to track your progress.

And do you. Not to put you on the spot or make it awkward, but I think with RPE and Zone 2, sometimes people don't know what that level is of. Like, if I'm talking like this, is that okay? Should it be like, I can only get one word out every five seconds? Do you kind of.

No. For me, I mean, it feels like if I'm on my bike doing a zone two and my wife comes in or one of my kids comes in to talk to me, I'm like, I can talk. I'm like, hey, yeah, okay. Yep, I got it. Yep, I'll pick them up. You know, do I want to sit there and talk? No, but I can if I could Talk like this. I'm in zone one. If you and I went for a walk, we're in zone one. In fact, you've rucked with me. Most of rucking is below zone two, except when you're going up the hills, which is brutal. Then you're not talking, then you're out of zone two. So there's very little of a ruck that's actually in zone two. The closest I can get to zone two is doing that shuffle run. I can do sort of a light shuffle, but if I'm walking, it's hard, but it's not hard enough. And if I'm walking flat, it's too easy. If I'm walking up a hill, it's too hard.

And another important piece is muscle mass. And I know you typically will kind of look at muscle mass based on metrics from a DEXA scan. And then there's also certain percentiles that you want to see patients in. So maybe talk a little bit about that, because that way anyone who's listening to this and is curious, okay, how do I stack up from a muscle perspective? Do I need to increase? Am I okay? They can go out and get one of these done relatively cheap, they're relatively easy to find, and there's a few core metrics. So maybe just talk about that for a second.

Yeah, I think everybody should have a DEXA scan. You just have to know this data. You have to know your bone mineral density. I think you have to know how much visceral fat you have. And I think you. You have to know how much muscle mass you have. Obviously, you're also getting body fat, which is important, but it's not as important as those other three. A DEXA scan will either automatically calculate for you or at least give you the data to calculate for yourself, something called the ALMI and the ffmi. So the ALMI stands for Appendicular Lean Mass Index. And again, sometimes it's just spit out in the report, but if it's not, you would simply go to the report where it shows you lean mass for left leg, right leg, left arm, right arm, and you add those three up, make sure they're in kilograms. So if they're in pounds, you have to convert them to kilograms, divide by 2.204 and then divide that by your height in meters squared. And if that's given in inches or feet, you have to make the conversion. So, and then you'll get a number, right? It could be 8, 9, 10, if you're a male, 5, 6, 7, 8, if you're a female, and then there are nomograms that will tell you for your age and for your sex what percentile you are in. And we want all of our patients to be at or above the 75th percentile for ALMI. And again, it's associative data, but it's very strong associative data, which is, look, muscle mass is a great integrator of exercise and strength. So hemoglobin A1c is a metric that is effectively an integral function for glucose. So you, you get this number 6.5, and it tells you directionally. Over the last three months, your average blood glucose has been 140 milligrams per deciliter. So the hemoglobin A1C integrated the area under the curve and spit out that number. And similarly, that's effectively what VO2 max muscle mass and strength are doing. They are integrators of the work that it takes to have a high VO2 max, to have high muscle mass, to have high strength. And the work that goes into that is the secret sauce. In other words, it's not so much the muscle mass. I think that is the most important thing. It's what you had to do to get said muscle mass and what that muscle mass will then do vis a vis metabolic function. And of course, the implication with respect to the functional side of things. So muscle mass and strength are not equivalent, and when put head to head, strength beats muscle mass as a predictor of lifespan. But all of these things are important metrics to be tracking.

So I think then the rest of the conversation will kind of focus on the actual training piece of it. Right. So that was the bulk of questions that we received, which is, how much should I be training, how much in the different pillars? How do you best train? Zone 2, how often, how many times a week, VO2 max. So I think we'll kind of now start getting into those pieces. But I think what would be helpful is we also received a lot of questions from people who are like, hey, I play basketball four times a week. Hey, I play tennis, I play golf. Hey, I like, I do marathons. I maybe just, I go to the gym and I lift. Is that okay? Or how important is it to actually be really specific to train for this and to hit all of those pillars?

Well, again, I think it depends on your objective. So everything has to be compared to the alternative. So if a person says, look, I'm playing tennis twice a week, I'm playing basketball twice a week, and I'm Lifting weights once a week. Am I doing great? The answer is, yeah, you are doing great relative to most people. But I don't think that that's a recipe for success if you want to be in the best shape possible in your last decade. And the reason being is sports, like any sport, whether it be basketball, tennis, swimming, any particular sport, has so much repetitive stress in it that you're going to develop movement issues, you're going to have asymmetries in joints and muscles, and you want to kind of balance those things out as much as possible. So again, if, you know, if you want to be able to play golf every week and you know you're going to walk five miles, that's great. But you have to acknowledge like every time you're swinging that club, it's asymmetric. So you have to think about what am I doing to counteract that. Same with tennis, same with basketball. And so again, it just depends on how much time a person is willing to put into this. You know, I don't want to suggest that everybody needs to do this because I acknowledge it's really difficult. If it wasn't difficult, everybody would be doing it already. You know, by definition, this is really a complicated idea. And maybe I just have the privilege of two things, right? One, I got to experience my marginal decade in my 20s. I had that back injury when I was 28 that left me unable to walk for three months and in so much pain I didn't know my name for a year. And during that period of time, I would have given my life to have had everything back. So when I got it back, it's just, it's seared into my brain, what it feels like to be so immobile, so debilitated and in so much pain. And I think that's just the greatest gift I ever received was to, to have that time machine to basically go and experience the last decade of my life and then get zapped back to being 28 with a totally different mindset of, yeah, I never want that to happen again, and at least I'll do everything in my power to make sure it doesn't. So long answer to a short question. But the reality of it is you really do need to be training very specifically. And that means a lot of really silly looking, unsexy things that I do every day. Sometimes as little as 10 minutes a day, sometimes as much as an hour a day, just on the stability stuff, just on the movement piece. But I wouldn't trade it for anything because the way my body feels, I'M thanked for it.

So now let's talk about stuff. If someone's listening, they're like, okay, I want to train for this and I'm willing to put in the work to the four pillars. So the strength, stability, zone two, VO2 max. Just to keep it simple, what's the minimum effective dose where it's okay, how much per week does someone need to commit to be able to hit those four things? And then we can get into each of them in a little more detail. But just from a minimum effective dose, if they have kids, busy job, families don't have a ton of time, what should they strive to set out for?

Well, it depends where you're starting, right? So the minimum effective dose if you're doing nothing is not that much. You're going to get huge benefits. When you go from nothing to probably three hours a week, that would be an enormous improvement. So I don't know that's the right way to think about it.

Well, let's maybe, let's just start there. So let's say someone starts at nothing. So you're saying, okay, start at three hours a week. How are you breaking that out?

Well, if you only had three hours a week to commit to this, you know, I think you'd have to put probably an hour of that into steady state aerobic training. Zone two, I think you'd have to put an hour of that into strength training. I think you'd probably want to put 20 minutes of that or 30 minutes of that across one or two sessions into high intensity aerobic training. So not hit intervals, by the way, but you know, sort of longer intervals that are VO2 max appropriate, and then the remainder of that time, call it another, you know, 30 or 40 minutes spread out at 10 minutes a day into some of the stability training. And again, I think it's important to understand if you say, look, I'm only willing to devote 60 minutes a week to this stability stuff, which seems so boring, should I just blast it out in one one hour session? The answer is no. You're better off doing 10 minutes a day, six days a week. There's really something to the neurologic pattern that comes from practicing your iap, practicing your breathing, your sick appular cars, your cat cow exercises. Doing that for 10 minutes every day is better off than just trying to do it all in one shot. So anyway, that's probably how I would structure a three hour program.

And for the, on the stability side, you kind of mentioned a few exercises there. And actually what you and Beth did Is we recorded those videos of you in the gym. And so those are available, Peter, at tmd.com outlive videos. And so anyone who wants to learn more about. Okay, what are those stability exercises that I could do 10 minutes a day, real short, real simple videos. You can go check them out. So we won't spend time double clicking on those because as you've stated before, it's. You really have to see it to understand it as opposed to just hearing about it. And so let's say then someone is like, okay, I'll start with three hours a week. How often do you ratchet that up? Does that get increased every week? Does it get increased every month? Is it when certain milestones are hit?

Well, it depends what the limiting factor is. So usually when a person starts at three hours per week, it's because that's the only time they're willing to put into it. Conversely, if a person's never lifted a finger and they say, oh, my God, I'm willing to do whatever it takes, and they only started three hours a week because you don't want to injure them, then you're in that situation where how much can you ratchet it up? And I'd probably ratchet a person up every six weeks in a scenario like that. But I think the far more typical scenario is, okay, I'm willing to do three hours. I do three hours a week. Usually a person sort of starts to habituate to that stress. And one of the important principles of training is a principle that most people have heard of called progressive overload. So in one way or another, the training, the load, the ask, needs to get more complicated, needs to get more difficult. So if you're talking about strength training, that could mean heavier weight, that could mean more reps, more sets, less rest between other things that make it more complicated, such as using bfr. So we're always looking for ways to make this more demanding. For example, in my stage now, I'm not adding time anymore. I am at the limits of how much I'm willing to spend on this. My kids are young. Every minute I'm doing that, I'm not spending time with them, or I'm not working, or, you know, I'm just falling behind in some other area of my life. So, you know, I'm already spending about as much time as I'm willing to spend in the gym. And it's probably on the strength side, six hours a week. So I have to find other ways to add that demand. The other thing I would be doing is thinking about where the deficits are. So let's say you have that person that's at three hours per week. Maybe their ALMI is already at the 70th percentile, and they're actually reasonably strong, but their aerobic training is an atrocity. So then I'm going to disproportionately add to that, as opposed to just equally build all of them. Conversely, we have a patient in our practice. Upon entering the practice, I mean, this guy's VO2 max was probably above 60, and he is 60, but he's been a lifelong runner, but he never touched a weight in his life. So he has very little muscle mass. And this is a guy who we're actually saying, look, we're probably going to need you to run a little bit less. And your running is amazing, and you're very fortunate that you haven't been injured doing it. We want you to keep running as long as you can. But we also have to address some of these other issues because you do have some of the really common issues of runners, some of the very common imbalances and things like that. So in his case, it was like, can we subtract a little bit of running time and start to get you doing strength training?

So people almost need to take just an inventory of what they're doing and where their strengths are. And that's where it's good to know, where is your VO2 max? How does your DEXA scan look? Can you farm or carry what percent of your weight? And if it's high and that piece is good, it's like, okay, keep training that, but then fill in those deficits. So we kind of hinted that the three hours per week really is for the people who are time limited. What about different ages? Because we did get a lot of questions of, I'm older, is it too late for me to start training for this? And if the answer is no, how should I think about that? Because I'm not as young, I can't quite bounce back, I'm not as strong as when I'm younger. They might be coming into this with not as much strength. And so when you have a patient like that, do you think about how they should tackle this differently? Are they on kind of a different program than if someone was 30? Kind of. How do you think about that from an age perspective?

Everybody's different. And age is definitely one of the factors that, you know, calls for sort of nuance around programming. I'll say this, and I think I've talked about this on a Previous podcast, I don't recall which one. There was a study that was done in Australia, I think we talked about on one of our podcasts, actually, where an investigator took a group of women with osteopenia or osteoporosis. So these women had very low bone density. They'd never exercised in their life. They were, if I'm not mistaken, no one was younger than in their mid-60s. They were probably, you know, in their 70s. And these women were put on a pumping iron regimen. I mean, literally like old school, in a gym, picking up weights, walking around. This wasn't like some fancy posh pilates class. This was pick up weights. And I think by the end of this study, one of the women may even got to the point where she was deadlifting her body weight. Imagine that 120 pound woman picking up 120 pounds off the ground. While that was a great example because it was documented in a clinical trial, there are so many stories of these things that you just see that I just have to believe that people are far more resilient than they can imagine. And I write about one example of this in the case of Barry. Barry is someone who gets mentioned in, I think it's in the stability chapter, actually. Here's a guy who traded his health for wealth, which is a pretty standard refrain, and then retired and had all the money in the world and realized, wait a minute, I can't do anything, my body hurts so much. And if you look at Barry today, I mean, the guy's functioning better than he was 20 years ago. So I think it really just comes down to being consistent and having a real sense of purpose around this stuff. And obviously you have to be smart about it. I mean, you can injure yourself in the process of these things. So having someone who knows how to kind of guide that and using common sense is essential. But I would never want anybody to come away from this thinking I'm too old to do anything about it. I think as long as you're breathing, you have a chance to do something about it.

On that front, you kind of mentioned osteopenia, osteoporosis. We did get a lot of other questions too, outside of age, which is, is there anything female specific that they should be thinking about as it relates to centenary decathlon? And I know DEXA scan, in addition to the muscle, it can also give bone mineral density, which is very important as we age. So maybe you want to talk a second about bmd and then also why that's something that maybe females specifically should be paying attention to thinking about and then ultimately how that leads to how they should be training.

Bone mineral density is very important for both sexes, but women are at a greater risk. And the reason for that is the way bones work. And I'm oversimplifying a little bit, but bones effectively have strain gauges in them and they respond to tensile stress. So when a muscle is contracting, the muscle via the tendon is attached to the bone, and as the muscle contracts, the bone is compressing. So imagine a strain gauge inside the bone that senses that that's a mechanical signal that gets converted into a chemical signal. So mechanical to chemical via estrogen. Estrogen is the hormone that does the signal transduction and that tells osteoblasts and osteoclasts, which are the bone building, bone reabsorbing cells to make the bone stronger, not weaker. So in other words, the use it or lose it philosophy is at play here. And estrogen is the key link. Now, men and women have estrogen, and it's very important for both sexes. The difference is women lose estrogen precipitously in midlife, and therefore women are more at risk for osteopenia and osteoporosis. Now, for men and women alike, it's very difficult to add bone density after you reach the critical period of maturation, typically in the early 20s. So unfortunately, most of our audience is past that point. I'm not sitting here having a discussion with teenagers, but of course, if I am, the answer is load bearing, load bearing, load bearing. Reach your genetic potential while you have a chance. But for those of us who are past that point, the key is how much can you slow the rate of decline? And nothing is more important for that than load bearing activity. And in fact, it needs to be heavy load bearing activity. Walking does not count as load bearing activity. Running, certainly better than swimming or cycling where you're not bearing load. But none of those compare to strength training. So strength training is really the most important piece of maintaining bone mineral density. And it must be supported from an endocrine perspective with the appropriate amount of estrogen and potentially testosterone, and certainly with the correct nutrition and supplementation, such as vitamin D and the right amount of protein and things like that.

One of the other questions we received is people were saying, hey, what if you can't afford a trainer, maybe don't have a gym to go to? How much of this can you do kind of without fancy equipment, maybe with body weight? How do you think about that in terms of as people are wanting to Train for this.

You can definitely do quite a bit of stuff with body weight. But I would also encourage people to say, if I don't have a lot of room, can I at least get some dumbbells and kettlebells? And, you know, they do make these dumbbells. They're not cheap, but they're efficient. And they're cheaper than buying all the sets where, as you know, one dumbbell has multiple links in it. So it could be £70, £60, £50, et cetera, depending on where you click it. So I feel like if you're going to think about, okay, what's the most efficient way to do this, I would say you do want to splurge on a few pieces of equipment. And certainly heavy enough dumbbells that you can get into carrying would be important. I think resistance bands are also really important. I've had a couple periods in my life where I haven't had access to a gym for three or four weeks. And during those periods of time, traveling with heavy resistance bands was essential. And if I could have added to that, having some dumbbells makes a big difference. So it's definitely easier if you have access to a gym or you can go to a gym. Like a TRX is probably another really great piece of device for people who don't know what that is. That's kind of this strap device that you either hang around a rack or something, or you can even put it behind a door. You just make sure the door is. You're on the right side of the door so the door can't open. And you can do a lot of exercises with that as well.

What about injury? So you kind of mentioned there earlier being conscious of if you're starting out just to not get injured. How should people think about this if they're either coming into it with previous injuries, if they're worried about injury, especially kind of in the older population, is that where the stability work can be much more effective? Is it if you haven't lifted much weight, start lower and work on positioning and how the movement works or how should people think about the injury piece?

This is something where I think you just have to be careful. And I don't think it would be reasonable for me to represent that I can offer an answer that would cover that in a broad way. For example, we did a podcast with Alton Barron looking at injuries of the shoulder, neck, elbow, hand. Was that like a six hour podcast?

It was very long.

It was definitely one of our three longest podcasts up with maybe Tom Dayspring and Matt Walker and that didn't even really get into the rehabilitation. That just talked about what's at the root of it. I've certainly done a number of videos with Kyler Brown where we've gone over some of my re foot post shoulder surgery. So I think the truth of it is you're just unfortunately, I hate to say this, it sounds like, but you've got to be able to align with people who understand how to not paint by numbers in their approach to rehabilitation. So maybe one way to help screen for that is basically when you meet a practitioner, just spending some time talking to them about their philosophy around your particular injury. For example, before I had my shoulder surgery, I wanted to understand all the details of early versus late mobilization, the trade off between range of motion and stability. These are trade offs. When you're repairing a joint as flexible as the shoulder, you can make it really stable again if you're willing to give up all range, motion and vice versa. I hate to say it, but I think you just have to become a more involved consumer of your care in that regard. But unfortunately I just can't offer some blanket piece of advice around injury.

But for the most part, even if someone's dealing with an injury, you would highly encourage them to not let them just give up on working out because of that injury.

No, I mean, if anything that should be motivation to get better. I mean, injuries, it depends where you are in your life cycle. But for most people who I think are listening to us right now, if you have a nagging injury and you take the approach of I'm just gonna sort of ignore it and it's not necessarily getting better, you're on a very slippery slope. I know someone very well who's had a shoulder injury for the last six months and it's not getting better. It's clearly not getting better. But more importantly, she's beginning to atrophy around it. She's becoming so weak and her pain is so significant around it that she's altered all of her movement patterns in response to this. She's younger than I am, so I sort of had a heart to heart with her recently and said what do you think the natural history of this is? Do you just think this is magically going to get better when you're 70? No chance. You need to do X, Y and Z right now. And yeah, that means you're going to have to invest at least three hours a week in doing this kind of rehab to see if you can get this better without surgery and maybe it will require surgery. I don't think it will actually in this particular case, but the alternative is worse.

Let's touch on VO2 max again. So a lot of people reached out and said, how should I train for VO2 max? So if you take away the only three hours a week to do everything, if it's someone saying, okay, my muscle mass is good, but my VO2 max sucks, what program should I get on?

So the first thing to remember is you've got to be spending if you're really committed to developing your cardiorespiratory fitness. I think I talked about this on one of the podcasts. Maybe it was on Tim's podcast. You're trying to maximize the area of a triangle. So the triangle has a base and the triangle has a peak. And the goal is, how big an area can I get? Not how wide, not how tall. You don't want one that's this wide and this tall. And you don't want one that's this tall and this wide. You want the max. The base is your zone 2, the peak is your VO2 max. From a training perspective, the rule of thumb that is applicable for people like us, I. E. Normal people and the best athletes in the world is roughly 80, 20, 80% of your volume is down here, 20% of your volume up here. In fact, some of the really, really elites are probably closer to 90, 10.

So you're saying no matter if you're just an ordinary athlete or you're the best of the best, it's still roughly.

The same Tadi Pogacar, who's the greatest cyclist on this planet, two time winner of the Tour de France, Absolutely mopping up the field of cyclists like they're children. That guy's doing 80 to 90% of his training at Zone 2. And I know that for a red fact because we know who his coach is.

So then let's maybe talk about that pyramid. So maybe let's just step back and.

Say, I didn't answer your question, by the way, about VO2 max, which we can come to.

Yeah, so maybe I was just going to say, maybe let's just cover the whole pyramid. So what's the training of the whole pyramid? If you know it's kind of 80%, 20%. Let's break out. What's going on?

So I just start with how much time am I willing to put into this? Now? I got to be honest with you, I wish I could be putting 10 hours a week into cardio. I mean, historically, I've put in 14 to 20 hours a week into cardio up until 10 years ago. So I really miss those days. I miss being insanely fit. I miss that terribly, and I miss the joy of that much training. It's simply not possible today for all of the obligations that I have. And I've done the math 10 ways to Sunday, I'd have to give up something I'm not willing to give up. I had to give up archery or give up driving or give up my kids or something like that. I'm not willing to give any of these things up. So I basically start with what's the most amount of time I can put into dedicated cardio? And for me, it's like four to five hours a week, not including rucking. I sort of keep that in its own bucket. So then it's a very simple calculation. 80% of that time is zone 2, and 20% of that time is VO2 max.

And how are you breaking out? Let's just start with Zone two. How many?

I divide it into four workouts a week. Tuesday, Thursday, Saturday, Sunday.

And do you always recommend doing it over, like. Let's say you could do four hours in one day. Is there the same benefit of doing all your Zone two in one day versus spreading it out?

You know, I've talked about this with Inigo. His view is if you can get at least 30 to 45 minutes, you should spread them out again. If you're only able to commit an hour to it, it might be one hour once or 30 minutes twice, but I'm sort of doing 45 minutes to 60 minutes each time is what I do.

Are you doing zone 2 VO2 max on the same day?

One of those days. So Tuesday, Thursday is just Zone two, and then two long sessions of stability training. Call it an hour of Zone two, An hour of stability, actually. Why don't I just walk you through the whole week? That'll be easier. So Monday is just strength training. So that's about 90 minutes to two hours when you include the stability training that I do as well. So movement prep, stability training, strength training, and that's all lower body. That's Monday. Tuesday is Zone two, followed by dedicated hour of stability. Wednesday is upper body strength and stability again, 90 minutes to two hours. Thursday is a repeat of Tuesday. Friday is a repeat of Monday. Saturday is Zone two in the morning, upper body strength, repeat of Wednesday in the afternoon. Sunday is zone two, followed by VO2 max.

And will you ever do VO2 max before you do zone two?

I generally don't, just because I Like to have a lot of reps before I go for broke. So even when I was like a cyclist and doing two VO2 max workouts a week, they were always preceded by the metric we would use on a bike was kilojoules. So it was, how many kilojoules of work would you do before you would do the super hard sets? And it had to be at least a thousand kilojoules, which would translate to at least a thousand calories of work for Zone two.

I know you said you kind of like to break it up. If someone is like, hey, you know, I can do four days a week of zone two, but I can only do 15 minutes a day, would you say?

Then I'd compress it. I would say do two 30s.

So in your zone two sessions, you like to do at least 30 at a minimum?

Yeah.

When you're in those zone twos, are you like when you hit the bike and the clock starts?

I do it all mine on a bike, sometimes on a treadmill. But what I do is the computer is programming to the Wahoo Kickr, which is the device I'm sitting on. So it's taking 10 minutes to ramp.

Me up, maybe just walk through. What modalities can people do? Zone two on? Treadmill, bike?

Anything that is steady state. So swimming is a great way to do it because you can really swim in a pool at a steady state. Running is a great way to do it because you can pretty much run at a steady state. Cycling outdoors is generally hard unless you have specific. Like, Fiesta island was a great place to train. I used to train at Fiesta island because for people who don't know where that is in San Diego, it's where all with the time trial bike races were. And it's just a seven kilometer loop that you can ride on without lights or any. Like, there's no traffic or anything that gets in your way. But for the most part, like, I wouldn't be able to do Zone two outside here in Austin. It's too hilly and there's too much traffic. It's fits and starts. I can do my VO2 max here because I go to a hill and that's my favorite way to do VO2 max is on a hill that's about a mile long. And just do very hard up the hill and then easy down the hill. A treadmill is another great way to do it. Just kind of a walking incline. Typically rowing machine, if you're really a good rower, you have to be efficient enough. Most people are not efficient enough. And they don't have the strength, they don't have the stability to row really well for 45 minutes. Stair climber is another really good one. Depends again, if you're starting out. Brisk walking is probably good enough too.

We don't have to get into all the reasons or the benefits of Zone 2 because we have so many podcasts with Inyugo San Milan people can listen to. But you kind of hinted at another thing there, which is when you start your Zone 2 workouts, you'll ramp up. But also a lot of times we get questions where, hey, I did a 90 minute workout and I was in zone two for 45 minutes of it. Am I good?

I think what you mean in that question is I went out for a three hour bike ride today. When I got back, my computer told me I was in. I did 44 minutes of zone two. So two issues there. One is that's just a zone two based on heart rate. That's generally the worst approximation of Zone two. So zone two really is more based on lactate if we're gonna be purely accurate or at a minimum RPE. But even if you posit that that 45 minutes of zone two from your heart rate is roughly accurate, it's not the same physiologically. Cause usually you're passing in and out of zone two in that situation. And so you're not getting kind of that constant steady state churn which you're looking for. What you're really kind of looking for is the harnessing of mitochondrial efficiency. And to do that, you have to be able to push oxidative phosphorylation right to its limit before you trip into glycolysis. And you're just at the limit of that glycolysis being the dominant energy source. Whereas if you're on that ride, you're going into and out of glycolysis constantly. So it's not that you're so much in zone two for 45 minutes as that you pass passed through zone two for a sum total of 45 minutes, which again, there's still value in that, but not for what we're talking about.

And what about VO2max? What modalities can you do VO2max training on?

You know, here I think it's probably easier in a way, right? Because it's pretty much anything that gets your heart rate up and gets you very tired. So, you know, look, it could be an air bike, it could be a regular bike, it could be a stationary bike, stair climber, treadmill running outside, you know, the sky's almost the limit. Something like burpees is probably pretty tough once you get into something that intense like jumping. Because the sweet spot for VO2 max is kind of three to eight minute intervals. So you don't want to be doing things that are so intense that you can't do them for at least three minutes. And so that's why I'd kind of hold off on that stuff. I mean, when I was young and I was really fit, I did a lot of it with jumping. But I can't jump for three minutes anymore. I'm not that fit anymore, so I have to rely on easier things.

What's your current VO2 max workout? So you mentioned kind of three to eight minutes on, is it?

Typically I do four on, four off is sort of where I spend most of my time. Sometimes three on, three off on a rowing machine. I got into that quite a bit last summer. But these days, and sometimes, by the way, I just, I'm in a bit of a rush and I'll just do one minute on, two minute off at a much higher intensity on the stair climber, so I have one of those like industrial grade strength climbers. And sometimes I'll just go sprint for a minute up the stairs and then takes me two minutes to get my heart rate back down to about a hundred and then repeat that for 20 to 30 minutes. So that's kind of like my poor man's cheating VO2 max workout. But what I really like to do is four minute repeats. Four minutes on, four minutes off, and.

On the four minutes on. Are you going 100% for the full. Like, how should someone think about, you.

Have to play with this. This is years and years of practice to know what that feels like. So again, I'm doing this on a bike, so I'm looking at wattage and my watts are so low now, I'm embarrassed. So I'm not going to tell you what the watts are because they're so much lower than they used to be. But I know I have a sense of what I need to average my wattage over those four minutes. So I might go out at 105% of that wattage. And it feels pretty easy for the first minute. If it doesn't, I've gone too hard by three minutes. I'm very uncomfortable in that last minute. That is at four minutes, I don't have much left. You know, if you go out all out in that first minute, you're not going to get to four minutes, you're just going to Crash. And you're. You're sort of not in that zone. There's no question. I positive split the thing, meaning I do more work in the first half than the second. But I don't want it to be more than about 10%.

How much of this can it improve for people? Right? So if people are saying, okay, I'm willing to put in the work for zone two, I'm willing to put in the work to increase my VO2 max, is this something if it's been two weeks, a month, two months, and they're not seeing maybe huge increases, they should get discouraged. I mean, I don't think you're going to get in your VO2 max tested every three months, you know, so it's. How should people think about just monitoring progress in order to see if improvements are happening, just to keep people motivated?

Well, again, it depends on what modality you're using. But, yeah, I don't think you need to test your VO2 max more than once a year. What you're looking for is you pick a modality and I'll give you an answer.

So let's take bike.

Okay, so again, most stationary bikes have a power meter. If you're riding outdoors, you'd probably want to have a power meter. I do think it's the great equalizer. So speed can be misleading because of wind and stuff like that. So you'll know how much wattage you can do. So when you start out, you might only be able to put out 150 watts for the four minutes, but if in six months, you're putting out 175 watts for those four minutes, assuming that your weight has an increased significantly, your VO2 max has gone up again. The other thing to keep in mind with VO2 max is weight plays an important role in it because it is VO2 max in liters per minute divided by your weight in kilograms. So if the name of the game for you is how do I maximize my VO2 max in total absolute terms, you can really game the system. My VO2 max when I was cycling was high because I was very light and I was disproportionately light in my upper body. And your upper body is contributing Nothing to the VO2 max for most tests because it's basically tested on a bike or on a treadmill. So you get punished for any upper body mass and you're only rewarded for lower body mass. So the lighter your upper body is, the better you are.

It can also be good motivation to people who, let's say on the Two by two nutrition framework. If you maybe are overnourished and you do lose weight while you're starting to get the cardio, you can see a good jump in your VO2 max if you're losing excess weight.

Yeah, it just comes down to how long you're willing to put into this. The literature on this suggests you can only improve your VO2 max by 50%. But the literature is typically looking at eight week studies. So what we're interested in is a lifetime of training. And in a lifetime of training you can increase your VO2 max by 50%. So there is a strong genetic component to it. You know, when you see these people who have freakishly high VO2 maxes in the 80s, there's unquestionably a strong genetic component to that, but they're also training like crazy.

Well, and you kind of hinted, right. Which is the goal for people who are wanting to start training for the Centenarian Decathlon for them is thinking about it based on their lifetime horizon. It's not something that's going to play out as I can train for this for six months. Like, it's not like I'm going to train for a marathon. After I train for the marathon, I'm going to go back to doing what I was doing. You really do want to create a program that you can keep up with for years and decades. And also you keep that timeline perspective of, okay, I don't need to increase at a sane amount because what I want to do is not get injured, be able to do something that I can do, find enjoyment out of it and find value. Well, that kind of took us that time. This was a little bit of a shorter AMA for us. We also just kind of speed around those questions, but hopefully people found some value out of it and just kind of to build off what they learned. But any last piece of advice that you would want to give people as they think about centenary Decathlon, as they think about their longevity journey. Again, kind of assuming people read the book, what advice would you give them?

Advice? Maybe not, but certainly incentive would be the following. We talk so much about the benefits of exercise in terms of how much it reduces the risk of chronic disease, how much it reduces all cause mortality. You've probably heard me say this before, but it's worth repeating. If I knew that all this training I was doing, everything I'm doing, if I knew that it was going to shorten my life by a year, I would still do it purely for the improvement in quality of life between now and the end of my life. The fact that it's not shortening my life by a year, the fact that it's probably adding five to seven years to my life and improving the quality of my life means day in and day out. I just think it's about the most important thing that I can do vis a vis my physical health. Other elements of health that we didn't get to. That would be sort of my parting thought. And of course, my parting comment would be a thanks to everyone who's listening to this. Because by definition, if you're listening to this, you were an early purchaser of Outlive. So I really want to thank you for that. Means a lot to me. I think I mentioned this once before on our podcast, but it's probably worth repeating. I never thought that a book would mean as much as it has in terms of how personal it feels and how attached to the thing that I feel as it's out there. And there's no other piece of content I've ever created. There's no blog post I ever felt this attached to or newsletter or podcast. There's just nothing. And this feels oddly personal. And therefore, whenever I go somewhere and I run into someone and they send me a message about it and they say, hey, I got your book. I read it. I really liked it to me. Means more to me than I thought I would. I'm sorry that I can't be thanking each and every one of you in person for purchasing the book as early as you did. Hopefully this is the next best thing. And so thank you very much.

And I should say too, the one thing I forgot to mention earlier is for anyone who has a physical copy of the book, if you haven't popped the jacket cover off yet and seen the actual cover, there is something on the actual cover too itself that was a special design. And again, shout out to no one's mentioned that yet. Not a lot. We gotten a few. But again, Rodrigo Corral and that whole crew, just awesome. Not only on the jacket cover, but the physical.

What's that called? The board. What do they call the hardcover of the thing? There's a name for that and I forgot.

I just call it the book. The book. It's a different question, but it's a little Easter egg out there for people, but awesome. All right, Peter, thank you very much.

Thank you very much. Thank you for listening to this week's episode of the Drive. If you're interested in diving deeper into any topics we discuss, we've created a membership program that allows us to bring you more in depth exclusive content without relying on paid ads. It's our goal to ensure members get back much more than the price of the subscription. To that end, membership benefits include a bunch of things. One totally kick ass comprehensive podcast show notes that detail every topic, paper, person thing we discuss on each episode. The word on the street is nobody's shownotes rival these monthly AMA episodes or Ask Me Anything episodes. Hearing these episodes completely access to our private podcast feed that allows you to hear everything without having to listen to spiels like this the Qualys which are a super short podcast that we release every Tuesday through Friday highlighting the best questions, topics and tactics discussed on previous episodes of the Drive. This is a great way to catch up on previous episodes without having to go back and necessarily listen to everyone. Steep discounts on products that I believe in but for which I'm not getting paid to endorse and a whole bunch of other benefits that we continue to trickle in as time goes on. If you want to learn more and access these member only benefits you can head over to peterattiamd.com subscribe. You can find me on Twitter, Instagram and Facebook all with the ID Peteratti md. You can also leave us a review on Apple Podcasts or whatever podcast player you listen on. This podcast is for general informational purposes only and does not constitute the practice of medicine, nursing or other professional healthcare services, including the giving of medical advice. No doctor patient relationship is formed. The use of this information and the materials linked to this podcast is at the user's own risk. The content on this podcast is not intended to be a substitute for professional medical advice, diagnosis or treatment. Users should not disregard or delay in obtaining medical advice from any medical condition they have, and they should seek the assistance of their healthcare professionals for any such conditions. Finally, I take conflicts of interest very seriously. For all of my disclosures in the companies I invest in or Advise, please visit PeterAttiamD.com about where I keep an up to date and active list of such companies.

Sam.