#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more

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 forward/subscribe. So without further delay, here's today's sneak peek of the Ask Me Anything episode. Welcome to Ask Me Anything episode number 68 and I'm once again joined by my co host Nick Stenson. In today's ama, we're going to go through many of the questions you submitted to us through the website and summarized as a way to answer some of the most common questions that have come through.

Through this, we'll cover a wide range of topics and frameworks. We cover topics such as how to assess cardiovascular health, what markers to pay.

Attention to, talk about intermittent fasting, including prolonged and time restricted fasting methods, as.

Well as alcohol consumption and its impact.

On health as well as the association with certain diseases. Talk about nutrition, outlining the principles of a well balanced diet and answering some of your questions about protein intake.

We also speak about the benefits and.

Downsides of ketogenic diets and low carb.

Diets, talk about exercise, including how to.

Create effective fitness routines, the importance of.

Recovery, and we explore the topic of wearables.

Lastly, we touch on emotional health. Needless to say, this is an episode that has something for everyone. If you're a subscriber, you can watch the video on the Show Notes page, and if you're not a subscriber, you can watch a sneak peek of the.

Video on our YouTube page without further delay. I hope you enjoy AMA number 68.

Peter, welcome to another ama. How you doing?

Good. Thanks for having me.

Always welcome on your own show. So today what we're going to do is we actually have gathered all the questions over the past three or so years that people have submitted on the AMA portal. For people who don't know, we have an AMA portal on our website where you can submit a question. So if anyone hasn't done it, we'll link to it in the show notes. And that way there's questions you have that you want follow up on, whether it's something related to something that happened to you, questions on podcasts, newsletters, whatever it may be. And so that's kind of what today's AMA is going to be. And we'll hit different diseases, we'll hit nutrition we'll hit exercise. We'll kind of hit a little bit of everything, because as people can imagine, questions came through, included a little bit of everything. So I think we'll just jump into it. But with that being said, anything you want to add before we start with the first question?

The only thing I would add is we talked about maybe if this format, which is more questions, less depth, more of how I would sort of answer questions if I were at a party and people were asking me if people want more of this. But on a personal level, we've talked about accommodating that. So maybe we just do a quarterly episode where I take very specific questions from individuals. If they want to be acknowledged, do so and do that. So, anyway, I think there's just a lot we can play with in this format. So let's just see if folks find this helpful.

Yeah, perfect. First question, how does someone assess their cardiovascular health? It's obviously a topic that we've covered in such a variety of podcasts. Very important. You've often talked about, number one, cause of death, not only in the US but in the world. And so kind of in general terms, if someone's sitting there thinking, okay, I'm curious about where I'm at cardiovascular, and as it relates to cardiovascular disease, how would you talk to them about how they can assess where they're at?

So, fortunately, if somebody wants to assess their risk of cardiovascular disease, we have a lot of tools to do it. We always start with the obvious, which is often neglected. But we should really know our family history. It's not enough to just know, my grandparents lived till such and such an age, or my aunt and uncles lived to such and such an age. Whenever possible, you really want to understand how grandparents, parents, aunts and uncles lived and died. And sometimes it's easier to ask questions like, hey, did they take medication or do they take medication for cholesterol, for blood pressure? And understanding those things, again, some of the patterns that tend to show up here, when you see people perishing really young from cardiovascular disease, or when you see them requiring procedures such as revascularization, stents, cabg, things of that nature, especially at a young age, you have to be thinking about heritable causes of ascvd. And again, the two most common are going to be LP and some form of familial hypercholesterolemia. Now, the latter is a lot easier to spot because these people have sky high cholesterol levels. The former is much more difficult because virtually nobody is getting their LP tested. And so that's sometimes the individual who themselves is kind of interested in assessing their own risk, is the first to figure it out, and then it explains what has happened over generations. So family history, very important. Then you can sort of think about understanding, hey, has there been any damage done to date? And here's where a calcium scan or a CAC can be a very helpful test. Now, it's not a foolproof test. It has its limitations. But if you think about the process by which damage occurs inside an artery, one of the final stages of that is the calcification of the artery, which actually is a protective mechanism. So the calcification of the artery per se isn't necessarily the thing that's going to kill a person, but it's indicative of very advanced disease. And if you see calcification in one part of an artery, it's quite likely that you have less remodeled plaque elsewhere in the coronary artery system. And in fact, those could be the ones that are at higher risk. So, again, a calcium score in an ideal world is zero. But it's always important to remember that there's about a 15% false negative, meaning somebody ends up with a negative CAC calcium score zero. But in fact, if you were to put them into a CT angiogram, which uses finer cuts of a CT and uses contrast after it does the initial calcium score, you'll see in 15% of those cases that there is indeed some calcification and or some soft plaque. So again, that's one more piece of information. And again, if you want to go to a level above the cac, then the CTA is valuable. But now you're experiencing more radiation, and you also run the risk of requiring intravenous dye or contrast, which again, is not a major risk, but it's non zero. The other things I really think a person can do to assess their risk of cardiovascular disease is obviously look at the lipid profile. So the two things we care most about here are APOB and lp. And the reason for that, of course, is APOB is the aggregate marker of all of the atherogenic proteins. Because LP is so disproportionately atherogenic, you have to look at it separately because even an elevated LP won't show up elevating in apob. The good news is, though, you don't have to concern yourselves with LDL cholesterol, non HDL cholesterol, HDL cholesterol, none of those things actually matter once you know the APOB and the lp. In fact, the triglyceride level itself doesn't matter unless it's dramatically elevated, sort of north of about 400 milligrams per deciliter, at which point you would actually need to manage that as well. Another thing that I think gets so overlooked but is so important is blood pressure. And it's just too easy to sort of go to the doctor once every two years, get your blood pressure checked, have it come back slightly elevated, have it be attributed to white coat hypertension, and then just sort of walk away from it. But the truth of the matter is we know pretty unambiguously at this point that having a blood pressure below 120 over 80 is, is absolutely the lowest risk and is the best way to reduce one's risk. And to be clear, that means that a blood pressure of 13085, which historically would have been considered normal, is anything but normal. Now, the challenge with measuring blood pressure in the doctor's office is it's almost rarely done correctly. Correctly means sitting there for five minutes, doing nothing, resting before the blood pressure is checked. It also means having a cuff that fits correctly, having the arm at the level of the right atrium, so about mid chest here, not having your legs crossed when it's checked. And I always like to check it in duplicate or triplicate. And if a person can do that twice a day for a couple of weeks, once a year, again, not a huge inconvenience in my view, then they can have a real assessment of their blood pressure. The other thing, of course, that's worth stating just for completeness, though I think everybody understands it, is smoking. If you're a smoker, you're at enormous increased risk of cvd. And of course, the same is true if you're metabolically unhealthy. This can be anything from hyperinsulinemia all the way to insulin resistance and type 2 diabetes. So those are really the big ones. There's a couple things I didn't include there. I don't really look at cimts. I don't find them to be helpful enough, and I think the data would agree with that. So I think that's probably 80% of risk assessment for cardiovascular disease is captured in what I just said.

If anyone wants to go deeper on any of that, as we said, we have tons of different materials, podcasts, newsletters, we'll link them in the show, notes for people who want to dive deeper on any specific piece of that. But next question that gets asked a lot is, how can I use fasting or intermittent fasting to improve my overall metabolic health? And I think a lot of times people use those two terms, fasting, intermittent fasting, interchangeably. And I know to you you kind of think of them a little separately. So it might be helpful to start with how you define those two terms before then getting into how each of them can impact metabolic health.

Yeah, I think the terms fasting and intermittent fasting get used interchangeably. I'm not going to represent that I'm the authority on any of this stuff. So I'm just going to tell you that whatever you are talking about, just make sure the semantics are clear so that you can normalize to what other people are saying. I typically don't use the term intermittent fasting. I use the term fasting and I use the term time restricted feeding or time restricted eating to describe what I think most people think of when they say intermittent fasting. But as a general rule, intermittent fasting or time restricted feeding or time restricted eating refers to periods of not eating during the course of a day. So when you hear people say I do 16, eight or 18, six, intermittent fasting, of course, what they mean is I'll go 16 hours a day without eating, eight hours a day of eating, or 18 hours without, and six hours with. Fasting is a term I kind of reserve for prolonged fasts, anything that's more than a day, and this will easily be 2, 3 days, up to really, really long fasts, 7, 10 or even 14 days. Then again, the term fasting implies that it's water only, it's non caloric. So whatever liquids you're getting during that period of time don't contain any calories. Okay, so now let's answer the question. How can you use fasting or time restricted feeding or intermittent fasting to improve metabolic health? Well, I think the data here are not particularly clear. So I'll start with the least clear of them all, which is the use of daily restrictions or intermittent fasting. Time restricted feeding. The data here suggest that this type of feeding pattern is no better than straight caloric restriction. In other words, when you normalize a person for the number of calories they consume during a day, whether they consume those calories across the course of the day, or whether they consume those calories in kind of a small feeding window doesn't appear to have a material difference. What does matter if a person is interested in improving their metabolic health is that they restrict calories. And if you recall, I kind of talk about this always through the lens of three tools that we have to reduce calories. The first is the direct way that you go about doing it, you literally just go about counting and reducing the number of calories you consume. Again, this is the most precise way to do it. This is why bodybuilders do it. You're not going to find a person on this planet that is more attuned to exactly what they put in their body and how that fuel gets partitioned. If you want an exact science, you go about counting every calorie and macro that goes in and you try to create that offset in that way. Again, for many people, this brings a lot of overhead with it. This brings a huge cognitive tax. And so we have two other techniques that can work quite well indirectly. So the first is what we've just been talking about, intermittent fasting or time restricted feeding, where you just say, look, I don't really want to pay attention to what I eat or even how much I eat. But if I just make the feeding window narrow enough, that has got to reduce the calories. And indeed it can not always. There's always the story of that person who in four hours a day of eating, still manages to eat 3,000 calories. But for the most part, as you restrict your feeding window, you're going to also reduce total calories. And then the third way to go about doing this is something called dietary restriction, which says, hey, I'm not going to concern myself with necessarily how much I eat, I'm not going to concern myself with when I eat, but I'm going to put in some pretty significant restrictions around what I eat. And again, the more restrictive you are, the more you're going to end up reducing calories. So I think that most important point to remember here is it's the calorie restriction that provides the greatest benefit. How you go about achieving it is really a function of your style. I actually recommend people try all of these techniques and we've covered them in so much detail elsewhere and the ins and outs of what the pros and cons of each are, because there are many pros and cons of each. I think I dedicate a pretty significant section of one of the chapters in Outlive to covering.

This next question on the list relates to alcohol. And it seems like anytime we've done anything around alcohol, it seems very polarizing. Let's say there's a lot of opinions, strong opinions on each side. And so I think the general question is how does alcohol affect someone's health or longevity and how do you think about it?

There's no denying that alcohol affects our health. Alcohol is a nutrient like Any other. But it comes with some particular issues that are a little bit unique to alcohol in a way that we wouldn't say are unique to carbohydrates, fats and proteins. And that basically is the following. Alcohol, in addition to being a dense source of energy, carbohydrates and Proteins come with 4 kilocalories approximately per gram, and fats are at about 9 kilocalories per gram. Well, alcohol is actually much closer to fats. It's at about 7 kilocalories per gram. But when we're really talking about the impact of alcohol on health, we're not even really talking about it from its caloric standpoint. Although I can tell you, having done more food logs with more patients than I can count, it is always amazing to see a patient's face when they recognize that 25% of their total calories come from alcohol if they're a moderate to heavy drinker. So you don't want to be dismissive of the calories, but I think for this question, Nick, I'm going to just put aside the caloric load of alcohol. So what we're really talking about is the toxicity that comes from the molecule itself, nominally through its metabolism in the liver and sort of its metabolic byproducts. Now we have a bit of a problem when trying to study this, which is we have to rely very, very heavily on epidemiology. Epidemiology is of course one of many tools we have to understand the impact of environmental, in this case potentially toxins, on health. But it just comes with so much baggage. Now, again, when you're talking about an environmental toxin that is really, really toxic, like tobacco, epidemiology turns out to be an awesome tool because the hazard ratios are so big that it's impossible for there to be other explanations. The problem is when you're dealing with alcohol, the hazard ratios are quite small. This is basically true of all food. And this is why epidemiology just doesn't serve as a great substitute for randomized control trials when it comes to understanding these things. The problem is we don't really have great RCTs around alcohol, and the ones that we have are very short lived. Now we did an entire AMA on alcohol, we have an entire premium newsletter on alcohol. So I'm not going to try to rehash all of that. So I just want to kind of give the top level stuff. So when you're doing these studies, one of the things you quickly come to realize is people who abstain from alcohol for A reason which is often where people are abstaining from alcohol. They're either former drinkers or they have health reasons that prevent them from drinking. There's often this paradoxical increase in mortality that we see. So if you kind of look at some of the larger studies here, and the largest one that I've seen is the recent one that came out in Jama last year, it included 107 cohort studies and nearly 5 million lives were studied. And it compared a bunch of different entities to lifelong abstainers. So usually these are people who often have religious affiliations or other reasons to have never consumed alcohol. Now when you compare former drinkers, so people who do not drink at all, but who used to drink, they have about a 26% increase in all cause mortality compared to lifetime abstainers. And again, that's kind of in keeping with what I said earlier, right? Which is these are people who used to drink, they don't drink now. There's usually a reason for that. Now interestingly, when you look at the occasional, the low volume and the medium volume drinkers, they actually didn't have an increase in all cause mortality. And just to put some numbers to that, occasional drinkers basically don't drink at all. These are people that are averaging less than a drink a week. The low volume drinkers are going to be up to a drink and a half per day. I wouldn't call that low volume, but that's how they were classified in that study. And the medium volume drinkers were up to three drinks per day. If that's medium volume, I need to recalibrate. But once you start to get into the high volume drinkers, these are people that are drinking three to four drinks per day and then the highest volume drinkers are over four drinks per day. These people start to see an uptick in their all cause mortality at 20 and 35% respectively, relative to the people who abstain. Now, if you look at these data and divide them by sex, you see another thing emerge, which is that across the board, women fare worse with respect to alcohol than men. So the first and most obvious explanation for this is simply body weight. So if you said like women who consume 45 grams of ethanol per day versus men who consume 45 grams of ethanol per day, of course the women should do worse. And I do think that body weight, and in particular lean mass, because remember, lean mass is where we see water and that's going to aid with the metabolism of ethanol. That's a part of it. But we also know that women contain less alcohol dehydrogenase, which is an enzyme that's responsible for the metabolism of alcohol. And the thinking at least is that if women have less alcohol dehydrogenase just genetically, then they're going to be more susceptible to the downsides of alcohol. So I think there's a lot more we could say about this. But the truth of the matter is, when you look across the board, alcohol is associated with at least three disease states, cardiovascular disease, dementia and cancer, in addition to what I just talked about, which is all cause mortality. Now, I want to point out one thing before we put this topic to bed, which is the Mendelian randomizations typically come up with a slightly different answer than the epidemiology. So the epidemiology usually shows kind of a flat curve for low levels of alcohol and then a ramp up of mortality as alcohol creeps up. Different studies and different cohorts are going to find different places. I generally tell patients that I think conservatively, one drink a day is, at least according to the epi, a minimal increase in risk. Whereas that JAMA study found you could get up to two drinks a day, maybe even three. It was only at three when you started to see the uptick. But the Mendelian randomization, which again is a technique where we look at genes that control a trait. So you might look at genes that control cholesterol or genes that control, in this case, alcohol consumption, because again, we know that there are certain genes that make it very difficult for people to drink alcohol. So if you believe that possessing those genes can speak to the phenotype of drinking. And I think this is a decent example of where Mendelian randomizations work. There are some where it doesn't. The Mrs. Show that at any increase in the consumption of alcohol, there is indeed an increase in mortality. So they show an increasing level. So we say that that means that the first and second derivative are positive. So any standard deviation, an increase in the consumption of alcohol leads to a greater increase in the risk of everything from hypertension to dementia to cardiovascular disease to cancer to all cause mortality. So how do we reconcile these two things? Well, I think it's kind of tough, right, because neither technique is perfect. But I think we sort of have to suggest that the precautionary principle here would be to obviously not consume alcohol at all because it's not an essential nutrient, there's nothing that it's doing that's good for you. And therefore after that you just have to be kind of judicious in your use and you have to ask the question, like, is this being maladaptive for my life in any other way? Does it, for example, impair my sleep? With the ubiquity of sleep trackers out there, I think most people will observe that if you drink a little bit too close to bed, your sleep is going to be disrupted. Does it change the way you eat? For example, if you have a drink or two in you, are you more likely to raid the pantry or the freezer and get ice cream? And then of course there's the much more destructive stuff like driving and things of that nature. So I think overall we can say that alcohol is under no dose helpful. Under low doses, probably not terribly bad, but under escalating doses it's actually quite negative.

How would you respond to a patient who says something in the following, which is what you kind of see a lot, which is, I understand that alcohol may not be good for me, but I do get a lot of enjoyment having a drink with some friends every other week or once in a while. Do you think that the danger of having a little bit of alcohol outweighs the potential enjoyment of being with friends in that environment?

I don't want to dismiss the importance and the benefit of social interaction and the joy that comes from that. I think it just comes down to the dose, truthfully. So if that person says to me, look, twice a month I like to meet my buddies and we like to play poker or we like to watch football and we have a few drinks, at the surface there doesn't seem anything wrong with that. But look, if the answer is twice a month, I'm just going to drink 12 beers. I have a hard time understanding how the pro social benefit of hanging out with your buddies that day justified having 12 beers. If the answer is I like to kick back three or four beers a couple times a month, then I would say, yeah, it's probably not that bad.

Moving on to the next set of questions. Kind of nutrition related. The first one is what do you think are the key principles for a quote unquote, well balanced healthy diet?

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 premium member. It's extremely important to me to provide all of this content without relying on paid ads to do this. Our work is made entirely possible by our members and in return we offer exclusive member only content and benefits above and beyond what is available for free.

So if you want to take your.

Knowledge of this space to the next level. It's our goal to ensure members get back much more than the price of the subscription. Premium membership includes several benefits. First, comprehensive podcast show notes that detail every topic, paper, person and thing that we discuss in each episode and the word on the street is Nobody's show notes Rival hours. Second, monthly Ask Me Anything or AMA episodes. These episodes are comprised of detailed responses to subscriber questions typically focused on a single topic, and are designed to offer a great deal of clarity and detail on topics of special interest to our members. You'll also get access to the show notes for these episodes, of course. Third, delivery of our premium newsletter, which is put together by our dedicated team of research analysts. This newsletter covers a wide range of topics related to longevity and provides much more detail than our free weekly newsletter. Fourth, access to our private podcast feed that provides you with access to every episode, including AMAs sans the spiel you're listening to now and in your regular podcast feed. Fifth, the Qualys, an additional member only podcast we put together that serves as a highlight reel featuring the best excerpts from from previous episodes of the Drive. This is a great way to catch up on previous episodes without having to go back and listen to each one of them. And finally, other benefits that are added along the way.

If you want to learn more and.

Access these member only benefits, you can head over to Peterattiamd.com subscribe. You can also find me on YouTube, Instagram and Twitter, all with the handle Peterattiamd. You can also leave us a review on Apple Podcasts or whatever podcast player you use. 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 all conflicts of interest very seriously. For all of my disclosures and the companies I invest in or Advise, please visit PeterAttiamD.com about where I keep an up to date and active list of all disclosures.