Tim Ferriss - Dr. Peter Attia

1)      Dr. Attia discusses the reason behind his muscle gain journey. He realized his muscle mass was significantly less compared to a decade ago and attributed it to excessive fasting- undergoing up to 10 days of water fasting multiple times per year. He still exercised throughout his fasting period, but he was not stimulating muscle protein enough since he was not providing amino acids to his muscles. He decided to increase his muscle mass by changing his nutrition and exercise routine, with a goal of being within the 90th percentile of appendicular lean mass index (ALMI), if not above the 97th percentile, since there is a correlation between a higher ALMI and a longer, better life. He gained around 13-14 pounds of lean mass in about 12 months without taking any anabolic steroids.

2)      Peter Attia discusses the importance of protein consumption for longevity and muscle hypertrophy. He suggests consuming 1 gram of protein per pound of current body weight and spacing out protein intake throughout the day for optimal absorption. Additionally, he recommends focusing on the quality of protein by choosing animal-based sources, as theyare more bio available than plant-based sources. When considering amino acids,Dr. Attia believes that leucine, lysine, and methionine are the most important for hypertrophy and advises tracking their consumption to reach the desired amounts.

3)      Dr. Peter discusses his consumption of branched chain amino acids (BCAAs) during workouts and why he no longer consumes them. He explains that while BCAAs are a potent stimulator of mTOR, which promotes growth, they do not stick around long enough in their free form and you are not getting enough of them. He also touches on the temporal nature of taking them and mentions their falling out of favor. Instead, he now only consumes an electrolyte drink during a workout and high-quality whey protein post-workout for muscle synthesis.

4)      Dr. Peter about the reluctance of putting out a book and the vulnerability that comes with it, especially when discussing personal and mental health issues. It's hard to delete a book from the world once it's published, unlike a blog post, so one has to take it seriously and take the time it needs to be of quality. The discussion then moves on to the importance of having objective, strategy, and tactics (OST) when it comes to achieving a goal such as living longer. The first step is to have a clear and concise objective, which should be followed by a well thought-out strategy before listing down the tactics. The death bars analysis is also mentioned, which is about understanding what ends life to understand what it means to live longer.

5)      Dr. Peter discusses the importance of avoiding chronic diseases, such as cancer and cardiovascular disease, in order to livelonger. He emphasizes that it's better to extend the period of time one lives without a chronic disease, rather than living longer with a chronic disease. He notes that once this strategy is established, one can then focus on the tactics, such as nutrition, exercise, and pharmacology Finally, he explains that despite the increase in life expectancy since 1900, there hasn't been much change in mortality rates due to chronic diseases.

6)      Attia explains the history of medicine leading upto Medicine 2.0, which brought us antibiotics, vaccines, and a focus on infectious disease care. He notes that Medicine 2.0 succeeded in solving acute care and infectious diseases, but has largely failed in addressing chronic diseases, which are responsible for the majority of deaths today. Dr. Attia also cites the success of medicine 2.0 in eradicating hepatitis C and rendering HIV a chronic disease.

7)     Attia discusses the lack of progress made against chronic diseases such as cancer, Alzheimer's, and type 2 diabetes despite modern medicine's efforts. He proposes a pivot towards a new way of thinking, which deviates from the traditional Medicine 2.0 approach, that focuses on prevention and modifying treatments based on patient-specific information, rather than solely relying on data from randomized controlled trials. By taking a more holistic view of health and incorporating factors such as nutrition, exercise, sleep, stress management, and emotional health, medicine can better equip itself to tackle these chronic diseases. Dr. Attia gives exercise as an example and explains how the current recommendation to exercise for 30 minutes a day may not be optimal for some patients and that medicine needs to become more individualized to be more successful.

8)      Peter addresses the issue of medical literacy and the challenges it poses. He mentions that medical language alone is complex,but the biggest issue is the lack of scientific literacy in the general population, which can lead to misinterpretation of studies and biased reporting.To improve scientific literacy, he suggests approaching learning as individual case studies, studying the basics of study types, and gaining hands-on experience by reading papers or taking courses. He also emphasizes the importance of understanding principles and refining objectives when learning a new skill, to avoid getting lost in the details.

9)      Peter discusses how one can become more literate in medicine and science. He suggests making it a part-time job with 3 - 4 hours per week spread across four consecutive days, layering things properly,and adding a couple of larger sessions for bulk memorization. To start with, he suggests listening to AMA Number 30, reading the case studies from the newsletter, reading “Bad Science” by Ben Goldacre, and “Outlive” by Dan Buettner. Dr. Attia also advises people to become familiar with the scientific method and how to design an experiment, which he believes can mostly be learned through practice in a lab.

10)   Peter discusses the importance of understanding basic medical concepts and terminology, particularly when dealing with a serious diagnosis. He encourages people to educate themselves on Sir Francis Bacon's approach and to look up Austin Bradford Hill and the nine Bradford Hill criteria used to scrutinize observational data to determine causality. Dr.Attia explains that observational studies are different from randomized control trials, as observational studies do not have an intervention, and causality cannot be determined without randomizing people to different groups. He advises people to be cautious of sensationalized headlines in the media and to aim for extending health span, not just life span.

11)  Attia discusses the importance of balancing sleep tracking with basic blocking and tackling aspects of sleep hygiene, such as food, alcohol, light, temperature, and noise. He recommends focusing on the fundamentals of what time you are getting into and out of bed, rather than becoming overly anxious about sleep trackers. Dr. Attia advises patients to remove their trackers and be less data-focused on sleep hygiene. However, he also acknowledges how sleep trackers can be useful in demonstrating how late-night food and alcohol disrupt sleep to motivate behavior changes. Additionally, Dr. Attia provides his personal rules for alcohol consumption, stating that drinking more than two drinks in a day with no good reason is not advisable, and drinking on more than three days a week is also not recommended.

12)   Peter discusses the usefulness of continuous glucose monitoring (CGM) in managing blood glucose levels, especially for people with type 2 diabetes. He explains that historically, people with type 2 diabetes have received poor dietary recommendations, but CGM technology can help individuals understand which foods work better for managing glucose homeostasis. Furthermore, Dr. Attia highlights that there is evidence that lower average blood glucose levels can lead to longer lifespans, even for non-diabetic individuals. While CGM technology is not commonly used for non-diabetic populations, Dr. Attia argues that it can be a useful tool for accurately measuring average blood glucose levels and making informed decisions about dietary choices.

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13)   Attia discusses the importance of having a high VO2 max and being strong for longevity. He explains that having a high VO2 max and being strong have more positive impacts on lifespan than any single negative impact caused by issues such as end-stage renal disease, high blood pressure, type 2 diabetes and obesity. He notes that almost everyone has the potential to be more fit and that going from the bottom 25% to the 25th to 50thpercentile of the population cuts the risk of all-cause mortality in half. Additionally, he emphasizes that strength is crucial in aging because it allows people to maintain their ability to move around easily and be pain-free.Finally, he explains the difference between type 1 and type 2 muscle fibers and how we lose power and explosiveness mainly due to atrophy of the type 2 fiber as we age.

14)   Attia discusses the importance of having a strategy in place for maintaining type 2 fibers and how resistance training is crucial for this purpose. To improve strength, Dr. Attia emphasizes the importance of both eccentric and concentric strength, explaining that eccentric strength or the force a muscle exhibits when lengthening is equally important but often ignored. One of the strength categories that Dr. Attia believes is crucial isthe ability to decelerate, which requires high eccentric strength. He recommends testing this ability through a broad jump and emphasizes the importance of doing both eccentric and concentric exercises, not necessarily in the same movement, to strengthen both types of muscles.

15)  Peter discusses specific exercises that promote longevity. He recommends starting with assisted exercises, such as the Nordic rollout, that require a significant amount of starting strength. One of his favorite exercises is the step up because it is a single leg exercise, a beautiful hip hinge isolation for the eccentric on the step down, and it doesn't have any axial loading. Dr. Attia emphasizes the importance of carrying heavy things because it's an essential skill for our species, and strong hands are one of the most correlated findings with longevity. He also recommends rucking, which is carrying a heavy backpack, as a great all-round way to combine strength and endurance exercises.

16)   Peter Attia talks to a guest about his methodology for Rucking, which involves using 55 to 60 pounds and doing an hour of Ruck on hilly terrain to push his cardio and force his body to decelerate. Attia also talks about how to improve VO2 max, which can be improved quite a bit if one has the proper methodology, like building a huge aerobic base that is the pure foundation before doing 20% of intense training. The sweet spot for improving VO2 max is being in the zone five, which is typically doing intervals about three to eight minutes, with a one-to-one work-to-rest recovery.

17)   Attia discusses the specifics of zone two training and how to determine the appropriate heart rate range or perceived exertion level. He mentions that measuring lactate with a finger prick device is a good indicator for people who are fit enough, with a lactate level of 1.7 to 2 millimoles being the zone. However, for those less fit, the rate of perceived exertion (RPE) is better, where one should be able to talk but not want to. Attia also recommends a minimum effective dose to start with, so depending on one's fitness level, two 30-minute zone two sessions would be great for beginners whereas three hours would be more ideal for those more adapted. Lastly, Attia talks about skinning on skis and rucking as exercises that have benefitted his body, with waist straps being important for those doing rucking.

18)   Peter Attia and Tim Ferriss discuss the benefits of using weighted backpacks for exercise, also known as rucking. They both recommend using a backpack with weight and investing in well-made packs, such as those from GoRuck. They attribute the benefits of rucking to the efficient loading of weight onto the hips and the ability to breathe fully. They suggest starting with a weight that is between a sixth and a quarter of your body weight and focusing on inclines instead of flat terrain. Furthermore,they discuss the implications of physical exercise on neuro degenerative diseases, such as Alzheimer's, and suggest that the Cartesian duality of body and mind is an illusion.

19)   Peter Attia discusses the link between exercise and reducing the risk of neurodegenerative diseases such as Alzheimer's, Parkinson's, and Lewy Body dementia. Through his analysis of scientific data, exercise has been found to be the most important modifiable behavior to prevent the onset of these diseases. Exercise not only improves movement reserve, but it also has hormonal, vascular, and metabolic benefits that improve insulin sensitivity and glucose disposal, critical factors in preventing the development of Type 2 diabetes, which has a strong association with Alzheimer's disease. He advises listeners to ask their physicians about maximizing insulin sensitivity, glucose disposal, and metabolic health through exercise and good nutrition to reduce the risk of neurodegenerative diseases.

20)   Dr. Attia suggests that, when finding a doctor, one needs to be clear about their objectives and take the time to understand the doctor's style or philosophy on prevention. To participate in modern medicine, one must learn outside of their medical training, and patients should understand where the doctor sits in terms of prevention and how they educate themselves. Tim contributes to the conversation by suggesting that one must have a certain level of medical literacy to assess their doctor's level of medical literacy, and that one's healthcare can go beyond their primary care physician, including trainers or exercise physiologists. Furthermore, they discuss a few tests to consider requesting, including apoe and apob tests, which are important metrics in understanding Alzheimer's disease and cardiovascular disease, respectively.

21)   Attia discusses various biomarkers that can help optimize health and longevity, including LP little a, APO B, APO e, uric acid, homocysteine, insulin, liver function tests, and cystatin C. He explains that creatinine, commonly used to measure kidney function, is inaccurate due to its insensitivity towards muscle mass, and suggests using cystatin C instead. On the topic of early cancer screening, Dr. Attia emphasizes the importance of treating cancers when detected early, and introduces Grail, a company that uses cell-free DNA to detect cancer and predict which organ it may have come from.

22)   Attia discusses how the sensitivity and specificity of a diagnostic test are only slightly useful without knowing the prevalence of the condition or pre-test probability. When it comes to cancer screening, the prevalence is generally low, and a low sensitivity test with high specificity will result in a high negative predictive value and low positive predictive value. However, when it comes to hormone-negative breast cancer, liquid biopsies are much more effective, with a 75% sensitivity in low-stage cancer. Attia suggests that we need to think of liquid biopsies in a different way from current anatomic screening methods, as they may provide a window into the behavior of cancer and its shedding patterns. Early detection is crucial, and it's unacceptable to die from colon cancer, which is the third leading cause of cancer death, according to Attia.

23)   Tim and Dr. Peter discuss the chapter titles of Attia's book 'The Science and Art of Longevity' and how hecame up with them, including the decision to include a chapter on emotional health. Attia reveals that the emotional health chapter was the hardest to write and that it was originally suggested as the first chapter of the book by Hugh Jackman. The chapter addresses the importance of emotional health in achieving a long and healthy life and includes 47 affirmations that were given as homework to Attia during his stay in a rehabilitation centre.

24)   Attia discusses the importance of positive affirmations in his journey to improve his mental health. He describes how difficult it was to come up with affirmations for himself until he had a breakthrough, and then was able to write the remaining 43 in just 20 minutes.He talks about how this exercise helped him fake it until he made it and fundamentally alter his view of himself, which was an important step in improving his mental health. He also discusses how including this in his book could help others who may be struggling with similar issues. Finally, he expresses his gratitude to those who take the time to read his book, acknowledging that it is not an easy read, but hopes that it will help people optimize their lifespan and health span.

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