The Peter Attia Drive

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**The Peter Attia Drive**

Expert insight on health, performance, longevity, critical thinking, and pursuing excellence. Dr. Peter Attia (Stanford/Hopkins/NIH-trained MD) talks with leaders in their fields.

Latest Episodes:

#196 - AMA #32: Exercise, squats, deadlifts, BFR, and TRT Feb 21, 2022

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Episode Description:

In this "Ask Me Anything" (AMA) episode, Peter shares his current workout regimen and how he incorporates blood flow restriction (BFR). He walks through the mechanics and fundamentals of some of his favorite lifts including squats, deadlifts, and hip thrusters and stresses the relative importance of each in the context of longevity. He touches on the relative importance of muscle size vs. muscle strength and discusses the impact of fasting on muscle mass and the potential tradeoffs during aging. Peter then dives into the topic of testosterone replacement therapy (TRT) for both men and women, starting with a clinical discussion around how he actually replaces testosterone in patients. He explains the targets of this therapy as well as the risks and benefits, and he gives his interpretation of current data on the association between TRT and heart disease.

If you're not a subscriber and listening on a podcast player, you'll only be able to hear a preview of the AMA. If you're a subscriber, you can now listen to this full episode on your private RSS feed or on our website at the AMA#32 show notes page. If you are not a subscriber, you can learn more about the subscriber benefits here.

We discuss:

Peter's current exercise routine [2:25];
How Peter incorporates blood flow restriction (BFR) into his workouts [5:45];
Relative importance of muscle size vs. muscle strength [16:45];
Comparing squats to deadlifts and why both are important [22:00];
Squatting technique and fundamentals [31:15];
Important cues to look for while lifting weights [38:30];
Proper mechanics of a deadlift [42:00];
Hip thrusters as an alternative to the squat or deadlift [44:00];
Split-leg work for simulating activities of daily living [47:00];
The impact of fasting/calorie restriction on muscle mass and the potential tradeoffs to consider [49:45];
Testosterone replacement therapy: considerations when contemplating TRT and Peter's approach with patents [54:30];
Data on the association between TRT and heart disease [1:04:15];
TRT for women—risks and benefits [1:06:45];
Impact of fasting on testosterone levels [1:13:45]; and
More.

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#195 - Freedom, PTSD, war, and life through an evolutionary lens | Sebastian Junger Feb 14, 2022

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Episode Description:

Sebastian Junger is an award-winning journalist, documentary filmmaker, and New York Times best-selling author. In this wide-ranging discussion, Sebastian shares stories from his time as a war reporter and how it shaped his understanding of the psychological effects of combat, including the sacred bond of soldiers, the forces that unify a tribe, and the psychological mechanisms that protect humans from painful experiences. He draws upon his personal struggle with PTSD as he discusses trauma as an all-too-common consequence of war and the importance of community in the healing process. He explains his interest in viewing human behavior through an evolutionary lens, including how it influences his parenting style, and he voices concerns over society's continuous shift away from our evolutionary roots. Sebastian also tells the story of his near-death experience and his new perspective on the possibility of an afterlife. Additionally, Sebastian shares his thoughts on the mental health implications of current events, such as the pandemic and the withdrawal of troops from Afghanistan, and contemplates what it really means to be "free" in modern society.

We discuss:

Sebastian's upbringing and early lessons about the evil of fascism [3:20];
Sebastian's search for a career, interest in writing, and what he loved about tree removal [11:30];
How Sebastian became a great writer [19:30];
Sebastian's experience with his Achilles injuries [25:30];
Work as a war reporter and his experience in combat in Afghanistan [28:00];
Psychological effects of war and Sebastian's own experience with PTSD [36:30];
The sacred bond of soldiers and what Sebastian learned from his time with troops in Afghanistan [48:30];
An evolutionary perspective on the forces that unify and bind tribes [1:00:00];
Hunter-gatherer societies, dealing with loss, and the ancestral connection to the spiritual realm [1:08:30];
Psychological mechanisms that protect humans from painful experiences and the power in giving thanks [1:13:15];
How parenting has changed Sebastian, and the incredible pain of losing a child [1:21:15];
PTSD and the influence of community on healing [1:32:15];
Isolation of modern society and the debate over young kids sleeping in bed with their parents [1:37:45];
Why Sebastian doesn't own a smartphone [1:43:30];
Parenting through an evolutionary lens [1:50:00];
Sebastian's near-death experience and new perspective on the possibility of an afterlife [1:54:00];
Sebastian's experience with depression and anxiety [2:12:00];
The pandemic's impact on mental health [2:16:45];
Sebastian's thoughts on the withdrawal of troops from Afghanistan [2:22:00];
Sebastian's latest book—Freedom, and knowing when to quit [2:27:00];
Defining freedom in modern society [2:44:30];
More.

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#194 - How fructose drives metabolic disease | Rick Johnson, M.D. Feb 07, 2022

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Episode Description:

Rick Johnson, Professor of Nephrology at the University of Colorado and a previous guest on The Drive, returns for a follow-up about unique features of fructose metabolism, and how this system that aided the survival of human ancestors has become potentially hazardous based on our culture's dietary norms. In this episode, Rick explains how the body can generate fructose from glucose and how circulating glucose and salt levels can activate this conversion. He discusses the decline in metabolic flexibility associated with aging, as well as how factors such as sugar intake or menopause-associated hormone changes can alter responses to sugar across a lifetime. In addition, Rick lays out strategies for combating the development of metabolic illness using dietary changes and pharmaceutical therapies, and he discusses the impact of fructose metabolism and uric acid on kidney function and blood pressure. He concludes with a discussion of vasopressin, a hormone that facilitates fructose's effects on weight gain and insulin resistance.

We discuss:

Unique features of fructose metabolism and why it matters [2:45];
A primer on fructose metabolism and uric acid [10:30];
Endogenous fructose production, the polyol pathway, and the effect of non-fructose sugars [22:00];
Findings from animal studies of glucose and fructose consumption [29:00];
What calorie-controlled studies say about the claim that a "calorie is a calorie" [42:15];
Implications for aging and disease [51:15];
Impact of endogenous fructose production on obesity and metabolic syndrome [1:01:30];
Why vulnerability to the negative effects of sugar increases with age and menopause [1:04:30];
Dietary strategies to reduce the negative impact of fructose [1:16:30];
The role of hypertension in chronic disease and tips for lowering blood pressure [1:30:45];
The impact of fructose and uric acid on kidney function and blood pressure [1:39:45];
The potential role of sodium in hypertension, obesity, and metabolic syndrome [1:49:00];
The role of vasopressin in metabolic disease [1:54:00];
More.

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#193 - AMA #31: Heart rate variability (HRV), alcohol, sleep, and more Jan 31, 2022

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Episode Description:

In this "Ask Me Anything" (AMA) episode, Peter and Bob first answer a variety of questions related to heart rate variability (HRV): what it means, why it matters, and how to measure, interpret, and potentially elevate it. Next, they dive deep into the topic of alcohol, beginning with a discussion on the negative impact that it can have on sleep. They then break down the confusing body of literature suggesting potential health benefits to moderate levels of drinking compared to complete abstinence and point out the limitations of these studies. Finally, they conclude by analyzing data on the impact of moderate and heavy drinking on the liver and on risk for Alzheimer's disease and dementia.

Please note: this AMA is audio only. If you're not a subscriber and listening on a podcast player, you'll only be able to hear a preview of the AMA. If you're a subscriber, you can now listen to this full episode on your private RSS feed or on our website at the AMA #31 show notes page. If you are not a subscriber, you can learn more about the subscriber benefits here.

We discuss:

What is heart rate variability (HRV), and why do we measure it? [2:10];
The association between low HRV and mortality risk [10:00];
What high and low HRV means and why athletes strive for a high HRV [15:30];
Factors that can raise or lower HRV [18:00];
How and when to measure HRV, and the best wearables [19:15];
Interpreting your personal HRV number and why there's so much individual variation [23:15];
How Peter's morning HRV reading impacts his decision to train [28:30];
Alcohol's impact on sleep [31:30];
Metrics to track the impact of alcohol on your sleep [34:00];
Alcohol's impact on the need to urinate during the night [39:00];
Alcoholic fatty liver disease (AFLD) [41:30];
Individual differences in the way people metabolize and react to alcohol consumption [44:15];
Analysis of epidemiology studies suggesting moderate alcohol consumption lowers mortality risk [52:00];
Alcohol consumption and Alzheimer's disease [1:05:15];
Heavy alcohol consumption and risk of dementia [1:08:30];
Chronic effects of alcohol on the liver [1:17:45];
The relationship between alcohol, sleep, and automotive deaths [1:20:45]; and
More.

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#192 - COVID Part 2: Masks, long COVID, boosters, mandates, treatments, and more Jan 24, 2022

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Episode Description:

This episode is a follow-up to our recent COVID-19 podcast with Drs. Marty Makary and Zubin Damania (aka ZDoggMD). Here, we address many of the listener questions we received about our original discussion. In addition to Marty and ZDoggMD, we are also joined by Dr. Monica Gandhi, an infectious disease specialist and Professor of Medicine at the University of California, San Francisco. In this episode, we talk about new data on Omicron, long COVID, masks, kids and schools, vaccine mandates, policy questions, and treatments. We also discuss some of the most prevalent misinformation and spend time talking about claims made by Robert Malone. We end with a conversation about our exit strategy.

Please note: we recorded this episode on January 17, 2022, and in an effort to get it out as soon as possible, this won't have full show notes or a video. Additionally, Monica was only able to join us for the first section of the podcast, so you'll hear her drop off partway through.

We discuss:

Severity of infection from Omicron—reviewing the data [5:15];
Factors contributing to the relative mildness of Omicron infections [8:30];
Is SARS-CoV-2 evolving to cause less severe disease? [13:00];
Potential of Covaxin—an inactivated virus-based COVID-19 vaccine [17:45];
How B cells and T cells work together to defend against viruses [22:00];
Comparing COVID-19 vaccines, and the rationale for the time between doses [25:30];
Reviewing the purpose and effectiveness of boosters for reducing severity and transmission [32:30];
Debating vaccine mandates, and putting COVID's mortality risk in perspective [41:00];
Why the topic of COVID has become so polarized [1:03:15]
Reviewing the data on masks for protecting oneself and protecting others [1:06:30];
The inconsistent logic used for mask mandates [1:16:00];
Long COVID and the potential for vaccines to reduce risk [1:21:45];
Risks for children and policies for schools [1:27:30];
Reviewing the outcomes from Sweden, where the government didn't impose lockdowns [1:31:00];
Draconian measures implemented in Canada [1:38:15];
Antiviral treatments for COVID and a common-sense approach [1:42:15];
Importance of ending tribalism and having rational discussions with humility [1:47:30];
Treating infection with monoclonal antibodies and convalescent sera [2:01:45];
Reviewing claims made by the controversial Dr. Robert Malone [2:11:15];
A potential exit strategy from the current situation [2:30:30];
Changes needed at the NIH [2:40:00];
More.

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#191 - Revolutionizing our understanding of mental illness with optogenetics | Karl Deisseroth M.D., Ph.D. Jan 17, 2022

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Episode Description:

Karl Deisseroth is a world-renowned clinical psychiatrist, neuroscientist, and author of Projections: A Story of Human Emotions. In the episode, Karl explains his unique career path that led to the development of optogenetics—a revolutionary technique that uses specialized light-sensitive ion channels to precisely control the activity of select populations of neurons. Karl provides a concise overview of how optogenetics works and how it can be used to better understand mental illness, to identify the neurons responsible for specific behaviors, and to guide development of new treatments. Karl uses his experience as a practicing psychiatrist to provide deep insights into depression, anxiety, autism, and personality disorders and explains the role of optogenetics in mapping out brain regions responsible for common mental health afflictions.

We discuss:

Karl's journey through medical school and interest in the brain [5:00];
A profound medical school experience that changed Karl's career path to psychiatry [17:30];
Karl's commitment to research and challenges overcome early in his career [27:00];
The state of psychiatry and mental health therapies when Karl started his lab in 2004 [33:15];
Neuroscience 101: fundamentals of neuroanatomy and neurophysiology [38:15];
Traditional techniques for identifying the brain regions involved in specific behaviors [47:15];
Intro to optogenetics and how to get a gene into a neuron [51:15];
How viruses helped make optogenetics possible [1:01:45];
How optogenetics was used to investigate the effects of dopamine neurons [1:15:45];
Appreciating the power of optogenetics [1:22:00];
Investigating and treating anxiety with optogenetics [1:26:45];
Autism and autism-related anxiety, and the potential of optogenetics in treating autism [1:38:00];
Optogenetics as a powerful tool for the discovery and creation of medical treatments [1:45:00];
Karl's inspiration to write his book, Projections [1:48:00];
Mania and bipolar disorder: evolutionary basis, symptoms, and the high prevalence in North America [1:52:45];
Depression: evolutionary basis and insights from optogenetics [2:03:15];
The effects of trauma early in life [2:18:45]; and
More.

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#190 - Paul Conti, M.D.: How to heal from trauma and break the cycle of shame Jan 10, 2022

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Episode Description:

Paul Conti, a returning guest on The Drive, is a practicing psychiatrist and recent author of Trauma: The Invisible Epidemic: How Trauma Works and How We Can Heal From It, in which he offers valuable insights on healing from trauma. In this episode, Paul explains how his personal experience with trauma and his many years seeing patients have shaped his understanding of trauma's impact on the brain, its common patterns and manifestations, and how often people don't recognize the implications of trauma in their own life. He discusses major challenges in recognizing trauma, including the lack of biomarkers in psychiatry and psychology, as well as the misguidance of the mental health system in targeting symptoms as opposed to root problems. He talks about shame as the biggest impediment to healing from trauma and offers solutions to how, as a society, we can start to change the stigma of mental health and allow more people to receive help. Finally, he concludes with a discussion about the potential role of psychedelics like psilocybin and MDMA in treating trauma.

We discuss:

Paul's background and unique path to psychiatry [2:30];
A personal tragedy that shaped Paul's understanding of trauma and resulting feelings of shame and guilt [5:30];
The current state of psychiatry training and need for improvement [20:15];
The over-reliance on outdated metrics and lack of attention to past trauma as impediments to patient care [28:30];
Defining trauma: various types, heterogeneity, and effects on the brain [34:30];
Importance of finding the roots of trauma and understanding the "why" [47:00];
The major challenge of recognizing trauma in patients [55:15];
How shame and guilt are barriers to treatment and healing [1:06:00];
How treating trauma compares to treating an abscess—a powerful analogy [1:11:30];
How evolutionary survival instincts create problems in modern society [1:15:15];
First step toward healing: overcoming the fear of talking about past trauma [1:19:00];
Shame: the biggest impediment to healing [1:25:15];
The antidote to shame and the need for discourse and understanding [1:34:15];
The emotional health component of healthspan [1:41:15];
How to reframe the conversation about mental health for a better future [1:52:00];
The growing impact of trauma on our society and the need for compassion [1:58:45];
Society's antiquated way of treating manifestations of trauma rather than root issues [2:04:15];
Potential role of psychedelics like psilocybin and MDMA in treating trauma [2:11:15];
Parting thoughts and resources for getting help [2:16:30];
More.

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#189 - COVID-19: Current state of affairs, Omicron, and a search for the end game Jan 03, 2022

Show notes

In this episode, Peter sits down with Drs. Marty Makary and Zubin Damania (aka ZDoggMD), both previous guests on The Drive. Marty is a Johns Hopkins professor and public health researcher and ZDoggMD is a UCSF/Stanford trained internist and the founder of Turntable Health. This episode, recorded on December 27, 2021, was in part inspired by some of the shoddy science and even worse messaging coming from top officials regarding COVID-19. In this discussion, Marty and ZDoggMD discuss what is known about the omicron variant, the risks and benefits of vaccines for all age groups, and the taboo subject of natural immunity and the protection it offers against infection and severe disease. Furthermore, they discuss at length the poor messaging coming from our public officials, the justification (and lack thereof) for certain mandates and policies in light of the current evidence, and the problems caused by the highly politicized and polarized nature of the subject. Themes throughout the conversation include the difference between science and advocacy, the messaging which is sowing mistrust in science despite major progress, and a search for what a possible "end" to this situation might look like.

NOTE: Since this episode was recorded over the holiday and published ASAP, this is an audio-only episode with limited show notes.

We discuss:

Comparing omicron to delta and other variants [4:15];
Measuring immunity and protection from severe disease—circulating antibodies, B cells, and T cells [13:15];
Policy questions: what is the end game and how does the world go back to 2019? [18:45];
A policy-minded framework for viewing COVID and the problem of groupthink [24:00];
The difference between science and advocacy [39:00];
Natural immunity from COVID after infection [46:00];
The unfortunate erosion of trust in science despite impressive progress [57:15];
Do the current mandates and policies make sense in light of existing data? [1:02:30];
Risks associated with vaccines, and the risk of being labeled an anti-vaxxer when questioning them [1:18:15];
Data on incidence of myocarditis after vaccination with the Pfizer and Moderna vaccines [1:26:15];
Outstanding questions about myocarditis as a side effect of mRNA vaccination and the benefit of boosters [1:35:00];
The risk-reward of boosters and recommendations being ignored by policy makers in the US [1:40:30];
Sowing distrust: lack of honesty and humility from top officials and policy makers [1:43:30];
Thoughts on testing: does it make sense to push widespread testing for COVID? [1:52:15];
What is the endpoint to all of this? [1:58:45];
Downstream consequences of lockdowns and draconian policy measures [2:05:30];
The polarized nature of COVID—tribalism, skeptics, and demonization of ideas [2:10:30];
Looking back at past pandemics for perspective and the potential for another pandemic in the future [2:20:00];
What parents can do if their kids are subject to unreasonable policies [2:25:00];
Voices of reason in this space [2:28:45];
Strong convictions, loosely held: the value in questioning your own beliefs [2:32:15];
More.

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Iñigo San Millán, Ph.D.: Zone 2 Training and Metabolic Health (Ep. #85 Rebroadcast) Dec 27, 2021

Show notes

Today's episode of The Drive is a rebroadcast of the conversation with Iñigo San Millán, (released on December 23rd, 2019). This episode with Iñigo was one of the most popular discussions to date and is a prelude to an upcoming follow-up discussion in 2022. In this episode, Dr. Iñigo San Millán, Assistant Professor at the University of Colorado School of Medicine, explains the crucial role of mitochondrial function in everything from metabolic health to elite exercise performance. Iñigo provides a masterclass into the many different energy system pathways, the various fuel sources (including the misunderstood lactate), the six zones of exercise training, and the parameters he uses to measure metabolic health. Additionally, he highlights the power of zone 2 training as both an effective diagnostic tool and, perhaps more importantly, as a treatment for mitochondrial and metabolic dysfunction. We discuss:

Iñigo's background in sports and decision to focus on education [3:45];
The various energy systems and fuels used during exercise [11:15];
Iñigo's qualification of energy systems into six training zones [19:30];
Lactate as an important fuel source [29:30];
Zone 2 training—physiologic characteristics, fuel sources, lactate, and the transition into zone 3 [37:00];
Using blood lactate levels (and zone-2 threshold) to assess mitochondrial function [43:30];
Accessing mitochondrial function by testing one's ability to utilize fat as fuel [51:30];
Athletes vs. metabolically ill patients—mitochondria, fat oxidation, muscle glycogen capacity, "fat droplets", and more [56:30];
Physiologic characteristics of zone 3, zone 4, and the lactate threshold [1:16:30];
Fueling exercise—dietary implications on glycolytic function [1:27:00];
Relationship between exercise and insulin sensitivity (and what we can learn from studying patients with type 1 diabetes) [1:43:00];
Metformin's impact on mitochondrial function, lactate production, and how this affects the benefits of exercise [2:00:45];
Raising awareness of the risk of "double diabetes" [2:11:30];
How to dose zone 2 training, and balancing exercise with nutrition [2:14:30];
Proposed explanation of the Warburg Effect: Role of lactate in carcinogenesis [2:23:30];
Doping in cycling, and the trend towards altitude training [2:35:45] and;
More.

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#188 - AMA #30: How to Read and Understand Scientific Studies Dec 20, 2021

Show notes

In this "Ask Me Anything" (AMA) episode, Peter and Bob dive deep into all things related to studying studies to help one sift through all the noise to find the signal. They define the various types of studies, how a study progresses from idea to execution, and how to identify study strengths and limitations. They explain how clinical trials work, as well as the potential for bias and common pitfalls to watch out for. They dig into key factors that contribute to the rigor (or lack thereof) of an experiment, and they discuss how to measure effect size, differentiate relative risk from absolute risk, and what it really means when a study is statistically significant. Finally, Peter lays out his personal process when reading through scientific papers.

If you're not a subscriber and listening on a podcast player, you'll only be able to hear a preview of the AMA. If you're a subscriber, you can now listen to this full episode on your private RSS feed or on our website at the AMA #30 show notes page. If you are not a subscriber, you can learn more about the subscriber benefits here.

We discuss:

The ever changing landscape of scientific literature [2:15];
The process for a study to progress from idea to design to execution [4:15];
The various types of studies and how they differ [7:30];
The different phases of a clinical trial [19:15];
Observational studies and the potential for bias [26:30];
Experimental studies: Randomization, blinding, and other factors that make or break a study [44:00];
Power, p-values, and statistical significance [56:15];
Measuring effect size: Relative risk vs. absolute risk, hazard ratios, and "Number Needed to Treat" [1:07:45];
How to interpret confidence intervals [1:17:30];
Why a study might be stopped before its completion [1:23:45];
Why only a fraction of studies are ever published and how to combat publication bias [1:31:30];
Why certain journals are more respected than others [1:40:30];
Peter's process when reading a scientific paper [1:43:45]; and
More.

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