Andrew Huberman - Dr. Peter Attia

1)      Dr. Peter Attia recommends two supplements to improve mental and physical performance. The first is "Element," an electrolyte supplement that contains salt, magnesium, and potassium without sugar to ensure proper hydration and cell function. He consumes one packet of Element with 20 to 30 ounces of water every morning and during mental or physical activities. The second supplement is "Hvmn Ketone IQ," which increases blood ketones without following a ketogenic diet. It is a preferred fuel source for the brain and body, providing better focus for cognitive work and greater energy levels for fasting exercise. He recommends visiting the websites of these supplements to claim discounts or free samples.

2)      Peter discusses the concept of health span and the three dimensions it encompasses: physical, cognitive, and emotional. He emphasizes that anything related to longevity must address all of these issues. He also explains the four horsemen of death, with atherosclerotic cardiovascular disease being the most consequential as it is the number one cause of death globally, followed by cancer. Cerebrovascular disease is another important cause of death, mostly occurring through embolic events. Thiscan happen due to hypertension, plaque build-up or ruptured plaques that immediately result in attempts to fix the problem.

3)      Attia emphasizes the importance of managing blood pressure to reduce the risk of strokes and heart attacks. He notes that hypertension is the leading driver of haemorrhagic stroke, and recent studies have shown that aggressively managing blood pressure to reach the 120 over 80 range is crucial. Peter also stresses the importance of properly measuring blood pressure as many people are walking around with high blood pressure without realizing it.

4)     Attia discusses the three big factors in preventing atherosclerosis: maintaining good blood pressure, not smoking, and avoiding high cholesterol.

5)      Peter and Andrew discuss the risks associated with smoking, vaping, and cannabis use. While there is no reason to believe that smoking cannabis is better than smoking cigarettes, Attia notes that the doseis significantly lower. Regarding vaping, he believes it is not a good idea but is probably the lesser of two evils if it helps a person stop smoking. The chemical constituents of vape and what people inhale are terrible and loaded with carcinogens, which is worrying because molecules cross the blood-brain barrier and are maintained in neurons for many years. Peter recommends that people avoid smoking and vaping and consider other delivery devices, such as patches, gums, and tinctures.

6)      Peter emphasizes the importance of being aware of what we inhale as the body absorbs it quickly. He mentions PM 2.5 data,which shows that particulates that are less than 2.5 microns get straight into the body, making it critical to avoid air pollution. Interestingly, Attia notes that arguments to promote cleaner energy should not solely focus on greenhouse gases and climate change; instead, they should recognize the impact of cleaner air on reducing air pollution and, consequently, saving more lives since more individuals die due to particulate pollution caused by burning coal than CO2 emissions from it.

7)      Peter discusses the importance of cholesterol in the human body, primarily for structural support in cell membranes and as a precursor to hormones. However, not every cell can produce enough cholesterol to meet its demand, especially during times of stress or illness, and the molecule is not water-soluble, making transportation a challenge. To solve this, the body uses lipoproteins that are part lipid and part protein. These lipoproteins come in two families, one derived from the liver, and the other from the intestine, each with unique functions in transporting cholesterol and other lipids throughout the body.

8)      Peter provides a detailed explanation of lipoproteins, specifically the APO B protein, which is responsible for getting cholesterol around the body. He explains that there are different types of lipoproteins that vary in size and densities, but the APO B lipoproteins are atherogenic and suggest poor cardiovascular health. Attia explains that most species do not have APO B, but humans do, and it's important to note that there is no evidence to date that suggests high levels of APO B reflect healthy metabolic needs.

9)      Peter discusses the importance of cholesterol in brain development, which goes against the popular belief that cholesterol is harmful. Studies show that cholesterol plays a crucial role in synaptogenesis, which involves the formation of connections between brain cells. Children have low levels of serum cholesterol, but they undergo CNS maturation without any problems; the explanation is that the serum is only a fraction of the total body pool of cholesterol. Attia also clarifies the difference between APO B levels and LDL cholesterol levels and emphasizes the importance of measuring APO B levels, which is a direct measurement of the concentration of LDL and VLDL particles and is far superior at predicting risk than the amount of cholesterol contained within them.

10)   Peter makes the point that APO B is causally related to atherosclerosis, so it is necessary not to wait until a certain point to do something about heart disease.

11)   Attia uses Mendelian randomizations to describe the causality of LDL cholesterol or APO B levels with atherosclerosis. He argues that medicine today is backward because we use risk calculations to predict 10-year mace risk and only modify cholesterol and APO B levels based on the risk values above a certain threshold, ignoring the fact that if a risk is causal and modifiable, it should be modified regardless of the risk tail or duration. So, if LDL cholesterol and APO B are causal, they should be modified. Attia suggests aiming for an APO B level of 60 milligrams per decilitre, which is at the fifth percentile of the population, while considering other risk factors to bring down the APO B levels to 30-40 milligrams per decilitrein case of any evidence of calcification, soft plaque, or family history of heart disease.

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12)   Peter explains how drugs like Statins and Acetamide work for regulating cholesterol in the body, and their side effects. Statins can cause muscle soreness and brain fog in a subset of people, while Acetamide has virtually no side effects since it acts outside the body. Statins can also lead to insulin resistance, which can be tracked via CGM. With regular CGM tracking, patients can be vigilant of the side effects and work with their doctors to find alternate medication or dosage to avoid side effects.

13)   Attia talks about a group of people with a genetic condition called familial hypercholesterolemia or FH, who have very high cholesterol levels and a high incidence of atherosclerosis. He explains that medications like Crestor and PCSK9 inhibitors can be effective in reducing cholesterol levels in such cases. He himself takes an injectable PCSK9 inhibitor drug, which blocks the protein that degrades LDL receptors, thus giving him more LDL receptors and yanks more APO B out of circulation. He also emphasizes that even if someone with high APO B levels may feel fine, they still need to take preventive measures as the best predictor of a heart attackis still a heart attack.

14)   Attia emphasizes the importance of low-intensity cardio, or "zone two stuff," and getting adequate sleep to improve vitality, emotional and physical health, and lifespan. He recommends three to four hours a week of zone two exercise and correcting over-nourishment. If those lifestyle changes do not work, pharmacotherapy may be necessary. Dr.Attia emphasizes the importance of kidney health, pointing out that compromised kidney function is associated with an even greater hazard ratio of all-cause mortality than heart disease. He notes that the kidney is sensitive to blood pressure and that using a more accurate biomarker than creatinine, such as systatin C, can help measure kidney function more effectively. Additionally, he cautions against the idea of a "French paradox" when it comes to alcohol - there is no dose of ethanol that is healthy, so people should avoidit to reduce their risk of cancer and other diseases.

15)   Attia discusses the risks associated with alcohol consumption. He argues that there is no dose of ethanol that can be considered healthy, although the risk of harm is very difficult to discern for most people up to one drink per day. However, after that, the risk climbs steeply and non-linearly. While there is emerging literature that places the limit at two drinks per week total, Dr. Attia advocates not drinking at all if possible. He also discusses the importance of quality sleep, noting that the impact of ethanol on sleep is under appreciated and that it can have significant impacts on both cardiovascular and cerebrovascular disease. Additionally, he notes that neurodegenerative diseases, particularly dementia, are heavily impacted by alcohol consumption.

16)   Attia discusses how consuming alcohol affects everyone differently, but for people who want to reduce their risk of cancer, it would be better to skip it altogether. Globally speaking, cancer results in approximately 11-12 million deaths per year, with a one in three or four chance anybody can get cancer in their lifetime. However, the probability of dying from it is only a one in six chances. There are several types of cancer, but it is essential to differentiate between germline mutations and somatic mutations. Germline mutations account for less than 5% of cancer cases, while somatic mutations are the driving force behind the development of cancer cells.

17)   Peter discusses two major drivers of somatic mutations, which are smoking and obesity. He argues that obesity is just a proxy for the two things that come with it, which are inflammation and insulin resistance. These two factors with inflammation and the immune dysfunction that come with insulin resistance and the stimulus that is caused, drives cancer. Environmental toxins such as asbestos and alcohol are also identified as risks of cancer. Dr. Attia highlights that we have less control over cancer than we do with cardiovascular disease, as we do not understand the disease well enough. Therefore, we need to rely on screening and lifestyle changes such as controlling smoking and insulin sensitivity to lower the risk of cancer.

18)  Generally, the first line of screening is visualization of cancers that occur outside the body using imaging, while for other inside the body, the use of an imaging modality is vital, although there is a problem with relying on any one modality since it might impact sensitivity and specificity optimization with radiation. MRI scanners are now used and have no radiation, making them the best option since screening using whole-body CT scans, for instance, incurs around 30-50 millisieverts of radiation, damaging cells in the body.

19)   Attia talks about the major sources of radiation and why it's important to understand the amount of radiation that one is being exposed to when getting an imaging study. He advises people not to get a CT scan or any imaging study without knowing the amount of radiation they will be exposed to, and to ask their practitioner for this information. He says that most doctors are now realizing the importance of ensuring that their CT scans are done with low levels of radiation exposure.

20)   Peter Attia discusses the challenges of aggressive cancer screening and the specificity problem that comes with stacking multiple modalities around it. Despite this, Whole Body MRI is used for cancer screening and has a high sensitivity but also has low specificity, which means it can identify things as cancer that are not. The typical cost of a Whole Body MRI is around $2,500, and patients can go to companies such as Pronuvo or Biograph to get a scan done.

21)    Dr. Peter discusses neurodegenerative diseases, with Alzheimer's being the most prevalent form of dementia and neurodegenerative disease, affecting roughly six million people in the US. While age is the primary risk factor for such conditions, certain genes like APOE4 isoform can increase a person's risk of Alzheimer's. However, it is not all bad news, and there are specific health routines, such as diet and exercise, that help reduce the chances of developing Alzheimer's and other neurodegenerative diseases.

22)      Peter discusses the current understanding of Alzheimer's disease as it relates to plaques and tangles in the brain. However, this understanding of the condition is now being questioned due to early papers in research being intentionally falsified, misleading the field for a decade. Despite the many bets placed on anti-amyloid treatments, they have yet to show effectiveness, and the field lacks the level of precision in practice seen in cardiovascular medicine. Nevertheless, certain lifestyle choices such as getting enough sleep, exercising, and maintaining lower lipids and glucose is incredibly important to maintaining good brain health.

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23)     Peter discusses how much exercise one needs to do and what type of exercise is best. According to his team's interpretation of the literature, the best use of three hours of exercise each week would be one hour of low-intensity cardio, one hour of strength training, and one hour of interval training. However, Dr. Attia suggests that if the brain really matters to someone, they should do more interval training. He also talks about head injuries and hyperbaric oxygen treatments for traumatic brain injuries,explaining how hyperbaric oxygen is not harmful but there is a lot of bad science regarding the treatment. He recommends using hyperbaric oxygen for wound healing but not much else, and the protocols for the treatment must be followed precisely in a real chamber.

24)     Peter also covers accidental deaths and mentions that overdoses from fentanyl, a synthetic opioid, have surpassed other categories of accidental deaths like automotive and falls. Counterfeit drugs and illicit drugs, which fentanyl often gets mixed with, have created a significant increase in deaths of despair, excluding automotive accidents. The number is reported to be up almost 20% per year since 2019.

25)      Peter discusses the importance of physical tests for assessing a person's overall health and mobility as they age. He uses the example of a broad jump to emphasize not only the importance of explosive movement, but also the ability to stick the landing, providing a brake system. Dr. Attia stresses that the ability to recover from falls becomes increasingly difficult as people age, with hip injuries being particularly challenging to overcome. Therefore, focusing on mobility and stability is essential in maintaining an active lifestyle and avoiding chronic pain. The four pillars of longevity through physical exercise are strength, stability, aerobicefficiency, and aerobic peak output. Stability, in particular, is important in differentiating those who age gracefully and those who don't. Dr. Attia also highlights how many machines in commercial gyms do not tap into stability, thus exercising in unconventional planes and movements is essential.

26)      Peter discusses how stability is multi-faceted and covers different aspects like building concentric strength and maintaining stability while doing easy movement. The conversation then moves to the book,"The Longevity Solution," specifically the section on emotional health. He explains how the last chapter is different from all others in the book, as it showcases his experiential knowledge, and it is not about expertise. Emotional health is the most important factor impacting quality of life, and without it, none of the other things matter.

27)      Attia discusses the importance of emotional health and how difficult it is to quantify. There is no single definition for emotional health, but components include healthy relationships and attachments, sense of purpose, emotional regulation, fulfillment, satisfaction, and being present. Attia admits that emotional health is the hardest for him to manage, despite having a clear understanding of pathophysiology and working hard to improve his physical health. Being present is a challenging aspect for many people, as thoughts about the future and planning can dominate the mind. Attia suggests that being present generally leads to a better frame of mind and cites a study that found people reported feeling happier when present in the moment.

28)      Attia discusses how he believes he could extend his lifespan by about 10 years through healthy habits, but suggests that focusing on the quality of life may be more important than lifespan. Attia also emphasizes the significance of relationships, urging people to question if they are living their life for resume virtues or eulogy virtues, as he found the latter to improve his quality of life during his own journey. When it comes to improving emotional health, Attia has practiced various behaviours daily, such as standing in front of the mirror for affirmations and journaling, but now he prioritizes being mindful and quick to act when something damaging occurs in a relationship. He uses the metaphor of Formula One to explain how safety measures and quick action decreases the severity of accidents, similarly emphasizing the importance of reacting quickly in preserving relationships.

29)      Attia discusses the importance of understanding oneself before approaching a person to understand or resolve a conflict. He stresses the importance of knowing what one is feeling and deconstructing the emotions to understand the actual cause of the conflict. Dr. Attia shares that he is still working on this aspect and often discusses his thoughts and feelings with his therapist. He highlights how coarse our emotional language is and how most of the time, we have no idea how we or other people feel. He attributes this to the lack of understanding of oneself, and hence, the need to first understand oneself before approaching a person to resolve a conflict.

30)  Peter discusses two experiences in 2017 and 2020 that represented total rock bottom moments in his life. He explains that these were the most difficult things he had ever done in his life and were emotionally difficult rather than physically. He also states that people like him can be overly analytical and these experiences made him realize that his hyper-analytical nature can lead him astray. In addition, he had an"aha" moment where he realized that emotional acceptance is different from intellectual acceptance and allowed him to accept and let go of emotional traumas.

31)   Attia discusses the importance of repurposing childhood circuitry to improve emotional health. While he acknowledges that revisiting childhood emotions can be emotionally violent, Attia shares his experience with utilizing dialectical behavioral therapy to learn from past experiences rather than dwelling on them. He shares a personal example of his anger and rage that he has had since childhood, which led him to boxing and an unhealthy inner monologue. After becoming aware of his own self-talk, he worked to change it and begin practicing self-compassion.

32)  Attia discusses an exercise he used to help him shed the trait of being an "insufferable prick" to everyone, including himself, that was proposed by his therapist during a treatment program in Arizona. The exercise required him to stop every time he had negative self-talk and pretend it was one of his closest friends who made that mistake, and record on his phone how he would speak to them in a kinder way. He had to text these recordings to his therapist, which helped him get rid of his negative, self-destructive internal monologue, which he referred to as "Bobby Knight." This exercise helped Attia realize the profound changes required to achieve both emotional and physical health and longevity.