Exercise, Nutrition, Hormones for Vitality & Longevity | Dr. Peter Attia

Welcome to the Huberman Lab Podcast where we discuss science and science based tools for everyday life. I'm Andrew Huberman and I'm a professor of Neurobiology and Ophthalmology at Stanford School of Medicine. Today My guest is Dr. Peter Attia. Dr. Attia is a physician who's focused on nutritional supplementation based behavioral, prescription drug and other interventions that promote healthspan and lifespan. His expertise spans from exercise physiology to sleep physiology, emotional and mental health and pharmacology. Today we talk about all those areas of health, starting with the very basics such as how to evaluate one's own health status and how to define one's health trajectory. We also talk about the various sorts of interventions that one can take in order to optimize vitality while also extending longevity, that is lifespan. Dr. Attia is uniquely qualified to focus on the complete depth and breadth of topics that we cover. And indeed these are the same topics that he works with his patients on in his clinic every day. Dr. Attia earned his Bachelor of Science in Mechanical Engineering and Applied Mathematics and his MD from Stanford University School of Medicine. He then went on to train at Johns Hopkins Hospital in General Surgery, one of the premier hospitals in the world where he was the recipient of several prestigious awards including Resident of the Year. He's been an author on comprehensive reviews of general surgery. He spent two years at the National Institutes of Health as a Surgical Oncology Fellow at the National Cancer Institute where his work focused on immune based therapies. For melanoma. In the fields of science and medicine, it is well understood that we are much the product of our mentors and the mentoring we receive. Dr. Attia has trained with some of the best and most innovative lipidologists, endocrinologists, gynecologists, sleep physiologists and longevity scientists in the United States and Canada. So the expertise that funnels through him and that he shares with us today is really harnessed from the best of the best and his extensive training and expertise. By the end of today's episode, you will have answers to important basic questions such as should you have blood work? How often should you do blood work? What specific things should you be looking for on that blood work that are either counterintuitive or not often discussed and yet that immediately and in the long term influence your lifespan and health span. What we talk about hormone health and hormone therapies for both men and women. We talk about drug therapies that can influence the mind as well as the body. And of course we talk about supplementation, nutrition exercise and predictors of lifespan and health span. It is an episode rich with information. For some of you, you may want to get out a pen and paper in order to take notes. For others of you that learn better simply by listening, I just want to remind you that we have timestamped all this information so that you can go back to the specific topics most of interest to you. I'm pleased to announce that the Huberman Lab podcast is now partnered with Momentous Supplements. We partnered with Momentous for several important reasons. First of all, they ship internationally because we know that many of you are located outside of the United States. Second of all, and perhaps most important, the quality of their supplements is second to none, both in terms of purity and precision of the amounts of the ingredients. Third, we've really emphasized supplements that are single ingredient supplements and that are supplied in dosages that allow you to build a supplementation protocol that's optimized for cost, that's optimized for effectiveness, and that you can add things and remove things from your protocol in a way that's really systematic and scientific. If you'd like to see the supplements that we partner with Momentous on, you can go to livemomentous.com huberman there you'll see those supplements. And just keep in mind that we are constantly expanding the library of supplements available through Momentous on a regular basis. Again, that's livemomentous.com huberman before we begin, I'd like to emphasize that this podcast is separate from my teaching and research roles at Stanford. It is, however, part of my desire and effort to bring zero cost to consumer information about science and science related tools to the general public. In keeping with that theme, I'd like to thank the sponsors of today's podcast. Our first sponsor is Thesis. Thesis makes custom nootropics that are designed for your unique needs. And to be honest, I'm not a fan of the word nootropics because nootropics means smart drugs. And to be honest, there is no such thing as a smart drug because there's no neural circuit for being smart. There are neural circuits rather for being creative or for task switching or for focus. And as we all know, different sorts of demands, whether or not they are cognitive or physical, require different types of cognitive and physical abilities. Thesis understands this and has created a kit of custom nootropics that are tailored to your needs. To get your own personalized nootropic starter kit, you can go to takethesis.com huberman take their three minute quiz and Thesis will send you four different formulas to try in your first month. That's takethesis.com Huberman and use the code huberman minute checkout to get 10% off your first box of custom nootropics. Today's episode is also brought to us by InsideTracker. InsideTracker is a personalized nutrition platform that analyzes data from your blood and DNA to help you better understand your body and help you reach your health goals. I've long been a believer in getting regular blood work done for the simple reason that many of the factors that impact your immediate and long term health can only be assessed from a quality blood test. And nowadays, with the advent of modern DNA tests, you can also analyze, for instance, what your biological age is and compare it to your chronological age. And obviously it's your biological age that really matters. The challenge with a lot of blood tests and DNA tests, however, is that you get information back about metabolic factors, hormones and so forth, but you don't know what to do with that information. 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I've talked over and over again on this podcast and on other podcasts about the fact that sleep is the foundation of mental health, physical health and performance. There's just simply no other substitute for a quality night's sleep on a regular basis. I've been sleeping on a Helix mattress for well over a year now, and it's the best sleep that I've ever had and that's in large part because the mattress was designed for me. What you need to know, however, is what's the ideal mattress for you? And you can do that by going to Helix site. You can take their brief quiz which will ask you do you sleep on Your side, your back, your stomach. Or maybe you don't know. Or maybe all three do you tend to run hot or cold in the night? Maybe you know, maybe you don't. At the end of that short quiz, they will match you to the ideal mattress for you. I match to the dusk, the dusk mattress. But again, that's what I need. 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Peter, thanks for joining me today.

Thanks for having me, man.

I've been looking forward to this for a very long time. I'm a huge fan of your podcast. I know that you went to Stanford and worked with a number of people.

That are colleagues of mine.

So for me, this is already a thrill just to. Just to be doing this.

Yeah, well, likewise.

I have a ton of questions, but I want to start off with something that I wonder a lot about and that I know many other people wonder about, which is how to assess their current health and their trajectory in terms of health and well being, specifically as it relates to blood work. So what are your thoughts on blood work? Is it necessary for the typical person? So this is somebody who's not dealing with some acute syndrome or illness. And at what age would you suggest people start getting blood work? How frequently should they get blood work? How often do you get blood work done, et cetera?

Yeah, there's a lot there. I mean, the way I talk about this with patients is first taking everything back to the objective. So what's the thing we're trying to optimize? So if a person says, look, I'm trying to break 10 hours for an iron man, I don't know that blood work is going to be a game changing aspect of their trajectory and their training. You know, they're going to benefit much more from sort of functional analyses of performance. So I'm assuming based on the question that you're really coming at this through the lens of living longer and living better through the lifespan. Healthspan most lens.

Yeah, and just I think most people have some sense of their vitality or.

Lack of vitality, but I think everyone.

Wonders whether or not they could feel better and whether or not blood work will give them a window into how they might go about feeling better.

Yeah, I think it does to some extent, but I also think that it has a lot of blind spots. So I kind of, you know, break things down into the two vectors that make up longevity, which are lifespan and healthspan. So lifespan is the easiest of those vectors to understand because it's, it's, it's pretty binary. You're alive or you're not alive, you're respiring or you're not, you make ATP or you don't. End of story. So what gets in the way of lifespan is essentially the four horsemen of disease. Right. So atherosclerotic disease, cancer, neurodegenerative disease, and metabolic disease, which directly isn't the cause of many deaths, but you know, basically creates the foundation to all of those other diseases. So, you know, if you're a non smoker, what I just rattled off is about 80% of your death. So how does blood work help address those? It varies. So on the atherosclerotic standpoint, it's a very good predictor of risk if you know what to look for. So primarily APOB would be the single most important lipoprotein that we care about. I can explain what that means in a second. And then also other markers of inflammation, endothelial health and metabolic health. When it comes to cancer. You know, blood testing in the sense of biomarkers is not particularly helpful outside of knowing that the second leading environmental or modifiable cause of cancer is metabolic ill health after smoking. So we don't actually know a lot about cancer in the sense of what causes it. It's really stochastic and it's a lot of bad luck. So we know that smoking drives it, and we know that even though epidemiologically we say obesity drives it, what it really means is metabolic poor health. It's probably the hyperinsulinemia that comes with obesity that drives it. So biomarkers help with that, but there's still an enormous blind spot to cancer. We could talk about liquid biopsies aside, because those aren't really biomarker studies, but put that away. On the neurodegenerative side, I don't think we have a lot of Insight that comes to understanding Parkinson's disease. But when it comes to dementia, particularly Alzheimer's disease, which is the most prevalent form of dementia, I think the biomarkers can be quite helpful. They overlap a lot with the atherosclerotic diseases. So the same things that, you know, drive the risk of heart disease are driving the risk of dementia. And then there's some novel stuff as well. If you include genetic testing, which you can get out of a blood test, we get a whole suite of genes, not just apoe, but far more, you know, nuanced stuff than that that can also play a role. So you can stratify risk in that sense. So in aggregate, I would say, you know, blood testing with biomarkers provides pretty good insight into lifespan. When you get into health span, you have kind of the cognitive, physical, emotional domains. I think here the biomarkers are far less helpful and here we kind of rely more on functional testing. So when it comes to sort of the cognitive piece, you can do cognitive testing in terms of long term risk. A lot of the things that imply good cognitive health as you age are in line with the same things that you would do to reduce the risk of dementia. So all the biomarkers that you would look to improve through dementia risk reduction, you would be improving through cognitive health. On the physical side, I mean, outside of looking at hormone levels and things which we look at extensively and understanding how those might aid in or prevent some of the metrics that matter, it really is, this is a biomarker aside thing. I mean, I'd be much more interested in a person's DEXA, CPET testing, VO2, max testing, zone 2, lactate testing, fat oxidation, those what I consider more functional tests that give me far more insight into that. And then of course, the emotional piece, which, depending on who you are, might be the single most important piece without which none of this other stuff matters. If you're a totally miserable human being, your relationships suck. I don't think any of this other stuff matters. And certainly there's nothing that I'm looking at in biomarkers that's giving me great insight into that.

Do you ask about emotional state or do you try and assess emotional state indirectly when you do an intake with one of your patients?

Probably not so much in the intake because I think it takes a while to form a relationship with a patient before that starts to become something that they're necessarily going to want to talk with you about. But I definitely think of it as an important part of what we do. And I Think without it, none of this other stuff really matters. Again, the irony of thinking about how many years I spent sort of in pursuit of fully optimizing every detail of everything without any attention being paid to that dimension is not lost on me. And look, there are some patients who they, that's just not something that, that's something that's compartmentalized. Maybe they're, you know, they're doing well in that department or maybe they aren't, but they just aren't willing to engage on that yet.

In terms of frequency of blood testing, if somebody feels pretty good and is taking a number of steps, exercise, nutrition, et cetera, to try and extend lifespan and improve health span, is once a year frequent enough? And should a 20 year old start getting blood work done just to get a window into what's going on, assuming that they can afford it or their insurance can cover it?

Yeah, I mean, look, I certainly think everybody should be screened early in life because if you look at like, what's the single most prevalent genetic driver of atherosclerosis is Lp. So unfortunately, most physicians don't know what Lp is. And yet, you know, somewhere between 8 and 12% of the population has a high enough. And depending on who you, you know, I had a recent guest on my podcast who suggested it could be as high as 20% have a high enough LP that it is contributing to atherosclerosis. So to not want to know that when it's genetically determined. Right. This is something that, you know, you're born with this and you only need to really check it once. Why we wouldn't want to know that in a 20 year old when it can contribute to a lot of the early atherosclerosis we see in people, you know, it just, it's, you know, it's leaving money on the table. In my opinion, the frequency with which you need to test really comes down to the state of interventions. You know, I, I don't think it makes sense to just do blood tests for the sake of doing blood tests. There has to be kind of a reason. Is something changing? You know, a blood test is for the most part a static intervention. It's a look at a window in time and there's benefit in having a few of those over the course of a year if you're unsure about a level. So if something comes back and it doesn't look great, yeah, it might make sense just to recheck it without reacting to it. But typically in patients we might check blood two to four times a year, but we're also probably doing things in there to, to now check, like, hey, you know, we, we gave this drug, did it have the desired outcome? You know, you put on three pounds of muscle and lost three pounds of fat. Did it have the desired outcome?

Speaking of tracking weight and fat, lean mass percentages, is that something that you recommend your patients do?

Pretty often.

I know people that step on the scale every day. I know people like myself that frankly might step on the scale three times a year. I don't really care. I pay attention to other things that are far more subjective. Maybe I'm making a huge mistake. What are your thoughts about quantitative measurements of weight, BMI for the typical person?

I think they're pretty crude. I think I'd rather take a DEXA annually and then maybe follow weight a little bit more closely to get a sense of it. And so with a DEXA, you're getting, @ least the way we look at the data, four pieces of information. Now, most people, when they do a dexa, should I explain what that.

Is? Yeah, I think some people might not know what dexa. In fact, I confess I have a crude understanding of what it is. Tell me where I'm wrong and hopefully where I'm at least partially right. My understanding is that there are a number of different ways to measure lean mass to non lean mass ratio. And there's one where they put you underwater. There's one where they put you into some sort of non underwater chamber. There's calipering and then there's the looking in the mirror and pinching and changing the.

Lighting. You know, it's funny, if you've done it enough, you can, I can sort of tell my body fat by my abs. So I can sort of tell by, you know, how good the six pack or how bad the six pack is, what the leanness is. And that's actually not a terrible way to do it. There are, you know, a bodybuilder, for example, which I've never been, can tell you the difference between being 6%, 7%, 8%, 10%, just based on the degree of visibility within the ABS. But basically a DEXA scan is an X ray. So it's the same principle as just getting a chest X ray where ionizing radiation is passed through the body and there's a plate behind the body that collects what comes through. And the denser the medium that the electrons are trying to go through, the less of them that are collected. So when you look at an X ray, as everybody's probably seen an X ray, that which is white is most dense. So if you had, you know, a piece of metal in your pocket, it would show up as a bright white thing. That's why ribs and bones show up as white. And the things that are the least dense, like the lungs, where it's just air, are the blackest and everything is a shade of gray in between. So Adexa is just doing that effectively. But it's a moving X ray. So you lay down on a bed and it takes maybe 10 minutes. And this little very low power X ray kind of goes over your body and the plate beneath it is collecting information that is basically allowing it to differentiate between three things. Bone mineral content, fat, other. And the other is quantified as lean body mass. So that's organs, muscles, everything else. So when most people do a dexa, they get the report back and the reports are horrible. I've yet to see one company that can do this in a way that isn't abjectly horrible. We've created our own templates, so we have our own dashboard for how we do this because we've just given up on trying to use theirs. But the first thing most people look at is what's my body fat? And this is the gold standard outside of like MRI or something that's only used for research purposes. So. So a DEXA is going to produce a far better estimate of, of body fat than calipers or buoyancy testing or things like that, provided the machinery is well calibrated and the operator knows how to use it. I've heard some people argue that in the hands of like the guy who's been doing calipers his whole life, it could probably be comparable with calipers. But nevertheless, for an off the shelf tech, DEXA is amazing. You know, of the four things that get spit out of the dexa, we think that the body fat is the least interesting. And so I would rank that as fourth on the list of what's germane to your health. The other three things that you get spit out are bone mineral density, visceral fat, and then the metrics that allow you to compute, like to basically compute what's called appendicular lean mass index and fat free mass index. And so those three metrics are significantly more important than body fat. And the reason is as follows. Right? So bone mineral density basically speaks to your risk of osteoporosis and osteopenia. And that doesn't sound very sexy to people our age. You know, 50 year old guys listening to this, it's like, yeah, Big deal. But for a 50 year old woman, this is a huge deal. Right. A woman who's just about to go through menopause or has just gone through menopause, is at an enormous risk for osteopenia and then ultimately osteoporosis, because estrogen is the single most important hormone in regulating bone mineral density. Oh. And we can come back and talk about why that's the case. But it's, it's very interesting how the, how the biomechanics of, of bones work and why estrogen specifically is so important. And this is a huge cause of morbidity. Right. So, you know, if you're over the age of 65 and you fall and break your hip, your one year morbidity is about 30 to 40%, which again, just to put that in English, if you're 65 or older, you fall and break your hip, there's a 30 to 40% chance you're dead in a year. Wow. Bones matter. So we want to really get a sense of where you stack up for your age, for your sex. And if you're anywhere off the pace, we have to ramp up our strategy and be super aggressive about how to increase that or at a minimum, prevent any further.

Decay. And are there age related charts for these sorts of.

Things? Yeah, this all gets spit out into what's called a Z score. So when you're looking at your bmd, it's going to give you a Z score. So a Z score of zero means. And you understand this, but it's like it's Z score referring to a probability distribution in a standard mode. So z score of 0 means you're at the 50th percentile for your age and sex. A Z score of plus one, you're one standard deviation above minus one below, et cetera. There's also a T score, which is doing the same thing, but comparing you to a young person. And so the T score is technically used to make the diagnosis of osteopenia or osteoporosis. We tend to look more at the Z score and basically say, look, if your Z score right now is minus one, in four years, I want your Z score to be zero. Not necessarily because you've increased that entire way, but maybe you've increased slightly while it's expected that you would have declined. I.

See. What are some things that we can do to improve bone mineral density at any.

Age? So it turns out there's a real critical window in which we are malleable. So depending on the age at which Someone's listening to us discuss this. You know, if you're, if you're under 20, 25, you are still in that time of your life when you are able to reach your potential. So it turns out that strength training is probably the single best thing you can do. And this was a surprise to me because we, you know, we did an AMA on this topic a little while ago, and that's when I got, you know, really deep on this with our analysts. My assumption was, oh, running must be the best, like some sort of impact. Must be the best thing you can do. It was. I assumed running would be better than swimming and cycling, but it turned out that powerlifting was probably the best thing you could do. And I think once you understand how bones work, it became more clear, which is powerlifting is really putting more of a shear force from the muscle via the tendon onto the bone. And that's what the bones are really sensing. They're sensing that shear force that's being applied through the bone in a compressive way, depending on the bone, of course. And that's what's basically activating the osteoblasts, which are the cells that are allowing bone to be built. So this turns out to be probably more important for females because how high you can get during that period of development, say till you're 20 or 25, basically sets your trajectory for the rest of your life. So where we get into real trouble is with patients who, for example, used large amounts of inhaled steroids during that period of their life because, let's say they had really bad asthma, or patients who needed large amounts of corticosteroids for some other immune related condition. So during their critical window of development, they were taking a drug that was impairing this process. So, you know, we have some patients like that in our practice and that's, you know, just an enormous liability that we're working really hard to overcome, you know, with nutrition, with hormones, with drugs, with training. And, you know, it's just something you have to be aware.

Of. I wasn't aware that inhalants for asthma and things of that sort can impair bone mineral.

Density. Yeah, if they're steroid based. Some of them, of course, are just beta agonists and they're.

Fine. So anything corticosterone, like, interesting. And then I always get asked this question, and I always reflexively want to say no, but I don't really know the answer, so I don't reply. What about topical corticosterone? You know, people will put cortisone cream. To me, it seems almost inconceivable that would have a systemic effect. But then again, what do I.

Know? It's all, it's all dose and it's all dose and time related. So, you know, if you're talking about like, I've got a little rash under my skin, I'm going to put, you know, corticosteroids on. Probably not, but, but certainly with enough of it put on. I mean, it is absorbed, so it could be an issue. But that's not typically what we're concerned with. I mean, we're mostly concerned with people that are, you know, taking even modest amounts of prednisone for months, years at a time, or like I said, kids that are using steroid inhalers for years and years and years. Again, I'm not suggesting that if your kid's on a steroid inhaler, they shouldn't be. You have to solve the most important problem. And if asthma is the most important problem, so be it. I think you just want to turn that into, okay, well, how much more imperative is it that our kid is doing things that are putting a high amount of stress on, on their bones and via their muscles to make sure that they're in that maximal capacity to.

Build. Do you think that somebody in their 30s or 40s or 50s could still benefit from strength training in terms of bone mineral density and longevity as it relates to bone mineral density? Given that there's this key window earlier, they might have missed that.

One. Oh, yeah, no, no. This is essential for the rest of life because you're now trying to prevent the fall off. So basically the way it works is you're sort of from, from birth to say, 20. You're on, you're in growth from 20 to 50. You plateau at 50. Men start to decline, but it's really small. Women start to decline and it's.

Precipitous and it's related to the drop in estrogen associated with menopause or.

Premenopause.

Correct. And, and can we get into any of the broad contours of what that strength training looks like? We had Dr. Andy Galpin on the.

Show. He talked a lot about ways.

To build strength versus hypertrophy versus endurance, et.

Cetera. I think there's pretty good agreement.

Across the fields of physiotherapy, et cetera, of physiology and medicine in terms of how to do that. But my understanding is fairly low repetition ranges. So this is anywhere from one to six repetitions. Typically not aiming for a pump, hypertrophy that sort of thing. But heavy loads that are hard to move, 80% of one repetition maximum or more done with long rest periods, three, two to three times a week type thing. Is that about.

Right? Yeah. If you look at the literature on this, it's going to tell you it's going to differentiate powerlifting from weightlifting. In other words, yeah, you do need to be kind of moving against a very heavy load. Now again, that can look very different depending on your level of experience. Like, I really like deadlifting now. I mean, I can count the number of days left in my life when I'm going to want to do sets over £400. But you know, I'll pick and choose the days that I do. But, but you know, I grew up doing those things. I'm comfortable with those movements. If I had a 60 year old woman who's never lifted weights in her life, who we now have to get lifting, I mean, we could get her to deadlift, but I think I wouldn't make, you know, perfect the enemy of good. I'd be happy to put her on a leg press machine and just get her doing that. You know, it's not as pure a movement as a deadlift, but who cares, right? We can still put her at a heavy load for her and do so safely. So now that said, I mean, there was a study that was done in Australia and I'm, you know, hopefully we can find a link to it. It's, there's a video on YouTube that actually kind of has the PI sort of walking through the results. I could send it to you after. Okay. Yeah, and it's, it's just amazing. They took a group of, you know, older women, they look like they were in their 60s or 70s, who had never lifted weights in their life, who, you know, had osteopenia and some probably already had osteoporosis. And they basically just put them on a strength training protocol. And it is remarkable to watch these women, they're doing good mornings, they're doing deadlifts, they're picking heavy things up off the ground. I think one woman was picking up, God, I want to say she was like picking like 50, 60 kilos up off the ground. I mean, just staggering sums of weight for these women who have never done anything and their bone health is improving at this age. So the goal frankly is to just, you know, never get to the point where, you know, you have to do this for the first time. You know, strength training is such an essential part of our existence that it's never Too late to start, but you should never.

Stop. Love that advice. Is it a systemic effect or a local effect? So for instance, let's say that. Well, my mother is in her late 70s. She actually used to be really strong when we were kids. She could move this fish tank that was in my room long before I could move it. And she's really strong over the years. I wouldn't call her frail by any means, but I certainly think she could benefit from some strength training. Let's say she were to start doing some leg presses or start even with air squats and maybe work up to some push ups. Are the effects all local? Meaning if she were to just train her legs or just do pushups, would it only be the loads applied to the limbs and muscles and tissues that were.

Involved? I think that's where the bulk of it is, yeah. Okay.

Yeah. So you need to train the whole body.

Essentially. Yeah. Now, keep in mind the diagnosis of osteopenia and osteoporosis is based on only three locations. The left hip, the right hip, and the lumbar spine. So, you know, that's just the convention by which we make the diagnosis. And I think part of that has to do with. That's where the majority of the insults occur. Now, not all of the insults. I've seen people that have, you know, because of horrible bone density, they're, they're, you know, they're fracturing ankles and tibia fibula, like they're having low tib fib fractures just walking. So clearly bone density outside of those regions does matter, but much of it is really focused on. And by the way, you know, you fall, you break a wrist. So. So this is a systemic issue, but the majority of the response is a local response because it really comes down to putting a load directly on that bone and then having that bone in kind respond by laying down more.

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Offer. You mentioned falling and the problems with falling and breaking things and mortality related to that. I wonder whether or not there are also health related effects of just having weak bones that are not just about falling and breaking a bone and dying a year later. Even that's obviously very severe because I think when people hear about that, some people might think, well, I'll just be more careful, I'll just move more slowly. I'll sit in a wheelchair if I need to, even though I might be able to walk if it keeps me from falling. Some people, I think, adopt that mentality. What are some of the benefits of having high bone mineral density for men and women that are perhaps independent of risk of injury? That some people might think, well, I'll just be more careful, I'll just move more slowly, I'll sit in a wheelchair if I need to, even though I might be able to walk if it keeps me from falling. Some people, I think, adopt that mentality. What are some of the benefits of having high bone mineral density for men and women that are perhaps independent of risk of.

Injury? Well, I think it's actually the inverse of what you just said, right? It's sort of like you have to sort of be able.