Transcript of #181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0

Peter Attia, welcome to the show.

Thank you for having me, Sean.

So I'm really excited about this interview. I've been diving into the health space pretty hard about the past month and had a bunch of your constituents on here, and it's like drinking from a fire hose here for me. So really excited to talk to you about everything that we're going to cover today. But real quick, everybody starts out with an intro. So, Dr. Peter Attia, you are the founder of Early Medical, a medical practice that applies the Principles of Medicine 3.0 to patients with the goal of simultaneously lengthening their lifespan and increasing their health span. You're the host of the Drive, one of the most popular podcasts covering health and medicine you frequent. Number one in the category. Congratulations. That's awesome. And like I said, I've interviewed a lot of your constituents and everybody has amazing things to say about you. You're also the author of the number one New York Times bestseller, the Science and Art of Longevity. You're also an accomplished long distance open water swimmer, including being the first male to complete the round trip between Maui and Lanai. I've heard that the only thing you do in moderation is moderation itself.

And like I said, I'm really excited to dive into medicine 3.0, but we had a little side conversation downstairs when we were getting started. So you're a hunter?

Yep.

How long have you been hunting?

About six years now.

What got you into that?

Well, I got into archery first just because I really love precision things. And I was just looking for another hobby and something to do and get really into. So I'd been doing archery for a couple of years and really enjoying it and really just enjoying it for the art of learning how to shoot a bow and arrow. And then a buddy invited me on a hunt and I was kind of ambivalent. I was like, I mean, okay, I get it. Like, I think it'd be pretty cool to kill something that you eat. And I think we just got lucky. You know, we got. We went to a place in Hawaii that was amazing and got to hunt a type of animal that is very difficult to hunt, called Axis deer, that is not only very difficult to hunt, but is very invasive to the state of Hawaii, incredibly destructive. And so it's. It's a win for the state, it's a win for the people of Hawaii. It's an important part of population control. And it turns out that I would say, along with elk, it's probably the most, you know, delicious sort of wild game there is.

And then the rest is history. You know, you sort of get hooked on it after that.

How often do you hunt?

You know, I would say these days I'm busier than I would like. So I, I probably went on five, probably went away for four or five hunts this year. But luckily in Texas we can hunt locally as well. We actually have access deer in Texas, so I can do, I can do some local hunting there as well.

The same deer that's in Hawaii?

Yeah. Although it's funny, they're the only two places in the US that exists is Texas and Hawaii. But it's a pretty different animal than Texas. It's a bigger animal based on its diet. In Hawaii it's, it's, it's smaller. And for whatever reason, it's, it seems just a little more skittish in Hawaii, but, but it's a totally different hunting experience. So in Hawaii, it's. You're hunting in the mountains. It's, it's pretty, it's pretty amazing.

Yeah. I started hunting this year for the first time. Just firearms. Yeah, I'm not into the bow stuff yet, but I love it, man. I think it's just awesome being out there and, and then through these health interviews and learning a lot about what our proteins are eating at the market and the hormones and the garbage food that they. I just had this guy on, Paul Saladino, and he was talking about, I asked him about wild caught salmon versus farm raised salmon and he started going on about the. What we're feeding the salmon. Holy shit, Ben. I mean, what do you. Is, did that play any role into why you started hunting?

No, I think it, look, I think it plays more of a role today. I feel pretty lucky that I can get away with eating mostly wild game or animals that are eating what they're meant to be eating. So I also have a friend in Austin who's got a large property and he farms, you know, in a sustainable way everything else that we eat. So even the bacon that we're getting is coming from pigs that are, you know, that are not going through the usual process. So, so there's, you know, I certainly hope that as more and more people are becoming aware of, it's hard to be healthier than the animal you eat. So you gotta be eating an animal that was pretty healthy to begin with. I hope that there are more and more economic choices for people to do this because right now it's a bit niche. Right. Not everybody can go out and hunt. My brother grows cattle and it's pretty awesome. So he's you know, he lives on a farm, and he basically regeneratively farms his cattle. And, you know, he and his family are only going to eat one a year, so they're selling all the rest of them and they're just kind of cycling through it.

But these are animals that literally just eat grass, just run through a pasture all day, and then when their life ends, it ends in the least stressful way possible, which say they don't know their life's about to end until they get shot in the head. Which I know sounds harsh to people, but it matters, right? It matters that an animal dies in the least stressful way.

Why is that?

Look, I think that there's, you know, if the end of an animal's life is incredibly stressful, there are a lot of stress hormones that kind of go through an animal's body, and I can't tell you that that necessarily makes a difference in the health of the meat. It certainly does make a difference in the flavor. I also think there's just something to be said for the humanity of it, right? Like, we are omnivores, right? We do eat plants and animals, but we don't have to be cruel about it. And I think we should all aspire to eat animals that have lived the best life that they can. And when their time comes, their time comes in the simplest and cleanest way.

Interesting. I mean, I'm just. It seems like everybody's moving to the farm to table stuff, at least everybody around here is. It's like a big conversation in the local area, and it seems like a lot more podcasts are starting to talk about that. I mean, how. How important is it, in your opinion? I mean, everybody's got their shtick, you know, and so. And some people really lean into it. I'm just curious what your opinion is on stuff like salmon or the cows eating.

I think it's a second or third order term. I think the first order term, if you want to just take a step way back and say, okay, what do we know is 100% true about nutrition? The answer is not a lot. Despite what health influencers might try to tell you, there's very little that we know is kind of what I call capital T true. So we know that eating too much food, regardless of what that food is, is not healthy. So we know that once the body is consuming calories in excess of what it can store safely, and different people have a very different genetic capacity for what that means. You and I could be different in that regard. In other words, you and I might have a different ability to put fat into the subcutaneous area around our waist, which, by the way, is a safe place to store excess energy. But at some point, any person will begin to exceed that and they'll start to put fat into places where it should not be. Fat should never be in your liver, it should never be around your organs. It should never be marbling inside your muscles.

It should never be interwoven in your pancreas, around your heart, or around your kidneys. Those are the danger zones. And once fat starts to accumulate there, which will happen in any form of excess energy, awful things are going to happen. And it doesn't matter if you're eating farm to table or if you're eating McDonald's. Now, one could argue if you are eating highly processed foods, it's an easier path to get there. And I agree with that. I think there's reasonable evidence to suggest that the more palatable, the less nutrient dense, the lower quality the food, the easier it is to overeat. But we just shouldn't lose sight of that objective, which is, you don't want to eat too much, and of course, you don't want to eat too little. Although that's less of a problem today, we should acknowledge it's still a problem. I think the second order term is you got to make sure you're getting enough protein for adequate muscle protein synthesis. I always joke about this in my. My wife teases me, you can't walk through the hospital hallway and interact with people in the final years of their life and find anybody saying, I wish I had less muscle mass.

So we all have to remember that gravity is working against us as we age. And sarcopenia, which is the loss of muscle mass, osteopenia, the weakening of bones, all of these things are enormous causes of age related morbidity and mortality. And so adequate protein intake, in addition to adequate caloric intake, are the two most important pillars. Then you can start to go, okay, well, okay, Peter, I get that. Now tell me what to do. And then, believe it or not, I think we get into a highly variable way that the body works. There are some people who do incredibly well on diets that are very high in carbohydrates. There are others who do incredibly well on diets that basically omit carbohydrates altogether. I was one of those people, by the way, for three years, from 2011 to 2014, I was on what was called a ketogenic diet. So that meant for three years, I think I had Carbs. Once, literally one day on my wife's birthday, I had three pieces of cake. And aside from that, I was. The only form of carbohydrates I had was like lettuce and some berries. But otherwise it was all protein and fat.

I did very well on that diet. It served me incredibly well. But for some people it did not. And that's fine. When you start to get into kind of some of the more minutia that people tend to fixate on, it's a little bit of majoring in the minor and minoring in the major. The evidence gets squishier and squishier. The arguments get more and more mechanistic and less based on actual data. So you can make a plausible argument that maybe you shouldn't eat that type of fat in favor of this type of fat, but there's no actual outcome data to the effect. So maybe time will tell. But I tell people that they should probably focus on the areas where we have far more evidence of doing X is beneficial, doing Y is not. For example, around exercise, sleep, and other things like that.

Why did you come off that diet?

So, truthfully, I got a little bit of food fatigue. You know, I just. And it wasn't that I was craving to eat like pasta and, you know, rice and potatoes again, but I was craving just a wider variety of fruits and vegetables and things that were basically going to kick me out of ketosis. And so I did. And, you know, I'm super happy to be eating what I eat today, which is basically I'm pretty much an in the middle eater. Right. Like, I wouldn't say I'm on a high carb diet. I wouldn't say I'm on a high fat diet. I'm kind of. I don't pay attention to any of it. You know what I pay attention to? I pay attention to how many calories am I eating? How much protein am I getting? Are the sources of my food as good as I can make them on a given day? On average, yes. Okay, that's. And by the way, all the biomarkers that any human is capable of checking, they're looking fine. I will use that to make sure I'm doing it correctly. If something were to change, I could revisit it. But I don't think that the incremental leanness that I might have had, because that was certainly a difference for me being on a ketogenic diet.

I mean, I was probably 6 or 7% lower in body fat than I am today.

Wow. Do you try to do. I'm just curious, you personally, do you try to do the farm to table stuff or do you.

Well, again, look, I think it's, it's. I'm pretty privileged in that between my access to hunting, you know, we were talking about this year, very fortunate that I had two elk tags. So not only am I going to feed my entire family with every form of elk you can imagine, right. I mean, we've got elk sausage, we've got elk steaks, we've got ground elk for burgers. I actually had to give away 500 pounds of meat. I had so much this year. So. So yeah, I'm in a fortunate position where because of my hobby I have access to that. But I don't, I don't tell people to fixate on that. Right. I mean, if you don't have access to farm to table, you can still go and buy at your grocery store grass fed. You can spend a little more and go grass fed instead of grain fed. And I think that's a worthwhile trade. You can still spend a little bit more and say, look, I'm going to opt into something that's organic, that hasn't been fed antibiotics without having to go all the way to farm to table. But if you live in an area where you can find a local farmer and say, look, I'm going to commit to half a cow this year with my family or, you know, a quarter cow or whatever is typically how they'll do it.

I mean, I think that's a great option.

You know, we're getting a little in the weeds before we really start here, but I wanted to. You brought up studies earlier and you know, I don't think it's any secret. Everybody is the. There's been a lot of distrust in the healthcare system and where these studies come from is big pharma. The only one doing the studies on the medicine that they're producing are the food companies, corporations doing the studies on the food that's coming out. And so kind of want to ask you, what do you think about those studies? Are they only. Is that who's conducting the studies and are there alternatives?

Yeah. So again, the term studies obviously is pretty broad. So if you look at most nutrition research that's trying to answer the questions that I think people want to know, they aren't actually funded by industry. They're typically funded by NGOs, they're funded by NIH. And you know, you're the list of people who's going to be more critical of NIH than me is not a very long list. I've been quite critical of, of things that the NIH has done, in my view, not correctly. Also, you could argue maybe I'm conflicted. I did my fellowship, my postdoctoral fellowship at the nih, so I spent two years there. And so I know the merits of nih. It's a remarkable system that gives the United States an insane competitive advantage in biomedical research like no other country on the planet has what we have access to, right? So we talk about things like why is the US Military so far superior to every military on the planet? Like, is there a second place there really? Like the gap between the US and everybody else is so enormous and a big part of it comes down to investment. And I would say the same is true from a biomedical research perspective.

Like nobody can even invest a quarter of what we invest in this.

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So we just have to acknowledge that that's a good thing. And, yeah, it still makes some mistakes. So the majority of people who are conducting this research are good people. They have varying degrees of competence and varying blind spots. But for the most part, when multiple different labs over multiple decades conduct multiple types of trials and the answers largely point in the same direction, you're sort of inclined to think that there's probably not much of a signal in the other direction. Now, when it comes to pharmaceutical stuff, there's a different pathway. Right. So here, pharma does need to pay independent investigators to do research because of the regulatory pathway to get drugs approved. Now, we might see in the new administration a revision of how some of that is done. I think that there have been mistakes that have been made in the way drugs are approved. I don't think it's nefarious. I don't think it's a conspiracy. People are very quick to attribute conspiracy to what I think is more readily attributable to incompetence at times, truthfully, or just people acting in their own best interest. Right. Like, you know, water always follows the path of least resistance.

So just because water goes down there doesn't mean like, oh, there's a conspiracy that the water's going down there. No. Like, that's what gravity and less resistance means. So as one example, I think that there should probably be fewer barriers during the lead up to approval, but more barriers post approval, in other words. I'll give you one example. It's a controversial example, but I feel strongly about it. Paxlovid was a drug that was approved to treat people with COVID Right. This was a drug. I believe it's a Pfizer drug. So if you got Covid, they would give you Paxlovid, and it was approved very quickly. But I think ask any doctor who's been prescribing Paxlovid for patients with COVID the drug doesn't work. Like, it just outright doesn't work. And by the way, it might even increase your risk of getting subsequent Covid. And while I can appreciate why the FDA wanted to see that drug approved quickly because of the way the world looked then. And especially if you're trying to treat people who are uniquely vulnerable to Covid, which would primarily be older people, I think where a lot of trust was lost in that.

It would have been great if they did follow up studies that six months later said, hey, this drug's been in the world today for six months, it's not working. We should pull the drug because a lot of money's getting wasted and frankly, a lot of people are being put on a drug. It's not harmful, but it's not helpful. Right? So why would we have a non helpful drug out there? So again, I know that that's a bit of a long answer, but I hope that I'm communicating the nuance of the situation, which is it's not black and white.

Thank you for sharing that. I'm curious too. Vaccines going, all these things are popping in my head that aren't in the outline. Vaccines are a major topic of discussion in a lot of homes right now. Everybody that has kids is wondering, me included, should we vaccinate our kids? Should we not? What do we do? And me and my wife have kind of set off on this journey interviewing a lot of different medical professionals. And it gets hard for somebody that's not a medical professional. Myself, what I find is we'll go to a practice and it feels like it's a sales pitch. It's a sales pitch on, we don't vaccinate, we're anti vax, you don't have to vaccinate your kids here. And it's like, that's great, but we still need a healthcare professional. We don't just need somebody to tell us, hey, don't vaccinate your kids at all. Like, what if my kid gets a broken arm? What are you gonna treat them with? You know, and it becomes like this sales pitch, you know, the whole pitch is we don't vax. Which, like I said, great, you don't vax, but what, what do you do here?

And other than tell me that vaccinations are horrible for my kids and for myself and my wife. And so I'm just curious what your thoughts are on vaccinations, if you have any. What should we be doing? What should we not be doing?

Well, this is a topic I've put more work into than I wish. I say that because it's not something I'm really interested in, to be honest with you. There are lots of things I'm interested in this is not on the list. Right. But I've had to put a lot of interest into it. I've had to put a lot of time into it, I suppose because of the position that I have found myself in where people are saying, hey, Peter, you're a very, very, very public facing physician and you're not in the quack category. Like there are lots of quack physicians out there. But we want to hear what you have to say. I also have a personal interest in it because I have three kids. So what have I learned? Well, I've learned that there are certain. So first of all, this is another topic that is not going to be a popular topic because people don't love gray. They want black and they want white. Nothing in science is absolute. It is all probabilistic. So there are very, very, very high probabilistic certainties and there were very, very, very low probabilistic certainties. So, for example, I know that if you have a certain type of infection and I give you this type of antibiotic, the probability that it will cure that infection and save your life is exceedingly high.

It's 99%. But I can't say with 100% certainty that every single person that has this infection to whom I give this antibiotic will be cured. Can't say that. That's not how biology works. And biology is the messiest of the sciences. So with that stated, I think there are some high probability certainties out there with respect to vaccine. I think there are some really gray areas and I think everybody needs to ask the question, what am I optim? So I will start that question with you. Right? What is it you are most afraid of as you think about vaccinating your kids? What is the mistake you're worried about? What are you afraid of and what are you hoping to achieve?

Well, I think something that I'm afraid of is there's a lot of talk and maybe it's rhetoric, maybe it's not about autism, you know, being caused by vaccines. Well, you know, me and my wife talk about this all the time and there's all the people out there that are, you know, my kid took the MMR shot, hasn't been the same since. And you know, and then there's the studies with the rise in autism. But are we testing more effectively for autism? Is, you know, there's got to be some sort of a scale like how autistic are you? Are we diagnosing more, you know, based off of that scale? Because more and More symptoms or whatever are becoming more prevalent. And so is that the reason that autism is on the rise? Is it just we didn't diagnose as many people because the symptoms were not as prevalent, or is there actually a rise? You know, and so that's one thing. Then there's all the, you know, the COVID stuff about the COVID vaccine. Is it giving people, you know, is it creating, you know, heart problems? Are people dying from the vaccine? I don't know.

You know what I mean? I know. I don't know what to think.

So. Well, let's just take those two examples. I think the second one's a lot easier because I think we. I think the answer there is. I would put it a little more in the more certainty category, although I think the previous one as well, we can. We can address. So when it comes to the COVID vaccine, one of the concerns, particularly with the MRNA vaccines, and particularly more so with the Moderna one than the Pfizer one, was you saw an above the baseline increase in myocarditis, in particular in young men. So myocarditis is an inflammation of the cardiac muscle. Now, you always have to remember when you're vaccinating millions of people, there's gonna be background noise. People get myocarditis all the time. You can get any sort of viral infection and get myocarditis. I've known countless people and seen in the hospital and been around people who have got myocarditis for no reason other than they got an infection. So you have to know there's a baseline level of this going on. But it really appeared that in particular for young men, teenagers and in their 20s, perhaps there was an uptick following that particular vaccine in the incidence of myocarditis.

To be clear, most of those men recovered without event. I think that the real mistake of policymakers at the time, because this would have been about 2022, was not acknowledging that. Right. Like, to acknowledge that is basically to say, hey, this is biomedical science. Things happen. And we don't always know when we do studies on a few thousand people what's gonna happen when it reaches a million people? Because if the signal is so small that it's only 0.1% of people, you're not going to pick that up at 1000. You gotta be able to do a million. And you're not gonna do that until it's out in the real world. So why not just acknowledge that and say, hey, that's a risk we should be aware of and we should Weigh that risk against the benefit. Because what's the harm to an 18 year old healthy male when he gets Covid? Well, we can quantify that. We know what that risk is. We've seen enough variants of COVID to know that is that risk worth that trade off? And I think reasonable people when presented with that set of facts can make their own decision. I know my decision for my kids in that setting when confronted with that information.

And it might not be the same as the next person, but that's okay. I think that's. We just want people to be able to make reasonable decisions based on reasonable information. But when it turned into there's nothing wrong with it, there's nothing wrong with it, you know, the sort of denying it, I think that cost a lot of credibility. And when parents got demonized for asking the question and saying, hey, should my six year old who's completely healthy really get this vaccine? And they got turned into bad people for that, I think that was a huge mistake. And again, I can tell you, taking care of countless people, I have patients that ran the spectrum across there. I had patients that said, I want me and my family to get every single vaccine there is. And I had other people that said, we're not touching this thing with a ten foot pole. And my job was not to talk anybody into or out of anything. It was simply to make sure they understand and can quantify the risk of both decisions and to be there and help them think through it. And that's it. So I hope that answers your question on the myocarditis.

Yes, there was indeed a real signal in absolute terms. It wasn't big, but in my opinion it was not worth the risk to young males. That was my, that's my personal opinion. I don't think it was worth the risk. And that means as such, I did not vaccinate my kids because they were otherwise healthy. I also feel very fortunate that we live in a state where it was not mandated and therefore we didn't actually have to pay a heavy price for it. So I also have empathy for people who live in draconian states where these things were shoved down their throat. But you know, when you live in a great state like Texas, they tend to defer to what the parents think is right, at least in this regard, around a COVID vaccine. And we just felt like, hey, wasn't necessary. Our kids are super young and healthy. Why put anything else into them that they don't need? That said, I take a different point of view on other vaccines. I think There are a number of vaccines where the risk of not vaccinating them is so much worse than the risk of vaccinating them.

The one in particular that I have looked into, more than all others combined, is indeed mmr. Because I think every parent who has been, and I say this word, deliberately misled by the fraud that came out of a guy by the name of Andrew Wakefield will always have in the back of their mind the lingering concern about autism. So, anger. Wakefield was a guy who has been more than discredited. So I say this again with. With. With. With. With complete clarity. He has been more than discredited for what he did to completely and deliberately and fraudulently manipulate data to make a case that the MMR vaccine caused Covid. I've done autism. I'm sorry, Caused autism. I've done a complete podcast on this, so if people are interested, they can. I interviewed the journalist who's done great work on this, and we kind of go through all the work. His name is Brian Deer. Not a pro vaccine guy, by the way. Doesn't care about vaccines one bit, despite the fact that he's been. People have tried to make him the face of mmr. He's like, nope, I just care about science. And this guy was the worst example of bad science.

So I can tell you with a very high degree of confidence without wasting the next three hours, why the MMR vaccine is safe and furthermore, why I think kids who don't get the MMR vaccine are really at risk of getting diseases that are much, much too significant to ignore an area where I do. Sorry, you're gonna ask a question, and I'll go to another direction.

I wanted to. I mean, I don't want to take you off your train of thought, so go ahead.

I was just gonna say, now, let's talk about an area that I would put in the middle. Cause right there, I'm saying on the one hand, again, I didn't think the COVID vaccine made sense for young, healthy kids. I really do think the MMR vaccine absolutely makes sense for all kids. So here's an area where I think the system is. Has kind of broken a little bit, and it's the use of the Hep B vaccine for kids early in life. So today, if a child is born in the United States, they are going to want to give them their first of their hepatitis B shots while they're in the hospital. Now, that has never made sense to me biologically, because unless the mother has hep B, in which case that makes sense. Because the risk of transmission is very high. And to be clear, hep B is an awful disease. So I'm not minimizing hep B at all. We have no treatment for it, we have no cure for it. If you have hepatitis B, the risk of getting cirrhosis and needing a liver transplant or the risk of requiring or getting what's called hepatocellular cancer is very high.

So you don't want hep B, but it's a bloodborne transmitted disease, like you're not going to catch it in the air. So if a child is born to a mom that doesn't have hep B, the risk that that kid's going to get hep B in the first five years of their life is virtually zero. And for that reason, I don't see the need to subject them to that vaccine immediately. But I also understand where the medical community is coming from, which is saying, hey, we don't want to miss an opportunity to give a vaccine because if we don't give it now, this kid might never get it. So there's a policy decision that needs to be made by people there. Personally, if it were me, I'd like to see it studied. This is where I actually would like to see the NIH fund an experiment, because I'm genuinely curious. Is it safe to give children that many vaccines that early in life, or should we limit them to the ones that are absolutely essential, where we know, hey, measles, mumps, rubella, smallpox, polio, these are devastating diseases. And especially if you have a kid that's gonna go to daycare where they're gonna be around a lot of kids and the risk of transmission if there's an outbreak is non trivial.

So again, we wanna eradicate smallpox and polio. MMR probably don't get eradicated, but we wanna protect kids against them. And hep B strikes me as something like, I don't think we need to do that right away, but I'd like to see it studied. So that's kind of three extreme examples of how to think about this. But as you can tell, given that it just took me 10 minutes to explain those three things at a superficial level, nobody wants to have this discussion. They just want to be black or white. Are you pro vaxx or are you anti vax? What about neither? Like, what about, I have a nuanced approach to every single one of these. If you're willing to sit down for three hours.

Yeah, yeah, that was actually, that was my question is, you know, do we, if we were to vaccinate our kids? Do we, do we break it up? You know, because, you know, we'll go to the doctor and they want to do, they want to do them all at once. And it's like, you know, like I said, for somebody that's not a medical professional, it's overwhelming. Is this too much?

Yeah, yeah.

In too small amount of time, do we try to drag this out, you know, so that it's one every month or, or what? I don't even know the schedule. I'm just saying, do we prolong this so that it's not so many vaccines in such a short amount of time?

Well, and the other thing to your point is some kids are going to have no problem. They're going to sail right through it. But you don't know if that's your kid. I mean, at the end of the day you're, you're, you're sort of, your goal is to figure out what's the best thing for your kid and whatever you can do to kind of minimize that risk. And of course the doctor is looking back at you and your wife saying, yeah, look, we're not opposed to spreading this out, but how do I know we're gonna keep you on schedule? Now there's also some nefarious stuff that I understand why it takes place, but the optics of it are really problematic. And that is that Medicaid reimburses physicians for vaccinations. So you'll hear that and people who are really in the anti vaccine camp will point at that and say that's a blatant conflict of interest. And the answer is it is and it isn't. It's not at all uncommon for Medicare and Medicaid to reimburse physicians to incentivize them to provide good care to patients, right? So just as if you have high blood pressure and you're on Medicare, you might have a physician who's being reimbursed.

If they can control your blood pressure better, that's viewed as a win win. Your life is better. Cause when your blood pressure is lower, there's less chance of a heart attack or stroke. The medical system is better off because you're now gonna cost the system less money by not having a heart attack or a stroke. And they wanna reward the physician by saying, here's an extra hundred dollars. Cause you managed to get Sean's blood pressure down. So that's, everybody agrees that that's kind of a good system. But when you now go into Medicaid and you apply that to Doctors are getting paid to vaccinate kids. Well, a couple things change, right. The first thing is we don't know the answer to the question you asked. Like, I don't know. I certainly don't know the answer. And I say this with humility. I don't know that anybody does. I don't know that anybody knows. We should just be ramming all the vaccines in the kids on day one to maximize them and make sure compliance is the highest versus can we take a more nuanced approach and spread them out? So right out of the gate, you take away some certainty.

So you lose a bit of the moral high ground to be able to say, I should be paying you to do this. Whereas in as much as you can have certainty in biology, I have pretty high certainty that if your blood pressure is normal, you're way better off than if your blood pressure is high. So that again, becomes problematic. But you can see how it can get twisted into something that it's really not interesting.

Thank you for that.

Can we talk about hunting instead? Yeah.

So I want to kind of do a little bit of a life story with you. But before we get started, I have a Patreon account. There are top supporters. A lot of them have been with us since the beginning. It's grown into quite the community over there. And without them, I wouldn't be sitting in here and neither would you. So one of the things I do is I give them the opportunity to ask each and every guest a question. And so this is from Christian. In a time when information is transmitted exponentially and health experts often present contradictory, contradictory views, how can we distinguish valid analysis from discourses influenced by biased personal agendas?

Oh, that's a very, very sophisticated, erudite question. Think a couple of things. I think. One, look at, look at people who are comfortable talking about uncertainty. So the, the more that a person is willing to speak in uncertainty versus certainty, I tend to believe them a little bit more. Right. So when a person tells you that it's their way, like, you have to eat this food and it's like it's. This is anything that's not. This is going to kill you, blah, blah, blah. Like versus well, we didn't. We, you know, maybe, maybe not. Like, so, so, so that's one thing. And then I think the second thing is you always have to mine for what a person's conflicts are, financial conflicts. So I think it should be required that anyone who describes themselves as, you know, a health influencer, slash, whatever, like, whatever you call people in this Category, they should all have a clear page of financial disclosures. It should be unambiguous. Exactly what, what companies have they invested in? Do they receive pay for promotion? Do they receive financial kickback or remuneration when they talk about a product? All of that should be fully, fully disclosed.

Just, you know, there should be no ambiguity about that. So I would say those are two really important ways to understand the credibility of who you're listening to.

Okay, that's a great answer. And then last thing, everybody gets a gift. I get really self conscious about giving these out to doctors, but vigilance, lead, gummy bears, you know, all kinds of stuff that's bad for you in there. But they do taste great. They're made here in the USA and it's kind of a mainstay for the show. It's been going on since.

Beautiful since we started. Thank you very much, but.

All right, let's dive into your life story. So I knew you grew up in Toronto and I think your parents came. Immigrated from Egypt.

Yep.

So what were you into as a kid?

I mean, the first sport I fell in love with was hockey, which is pretty, pretty typical in Canada probably at the time. Honestly, there were. Today, I'm sure kids will have more of a well rounded sporting background with, you know, the NBA is there. But yeah, it was pretty much just hockey Growing up from a very young age until, until, until my second love came, which was boxing.

Boxing, nice. What were your parents? What did they do?

So my dad ran a restaurant and my mom worked at the restaurant with him. I mean, she, when I, when she, when they came over, you know, she worked at a, at a checkout, you know, worked in a, like a variety store, grocery store at the checkout. And then by the time I was born, she was mostly working at the restaurant with my dad.

Any brothers, sisters?

Yep, I got a younger brother and a younger sister. So I was the three.

You guys get along very well. Yeah, still close.

Very close.

What other. I mean, were you a good student? Were you, were you into medical growing up?

No, no, not at all. Yeah, I think I was, I was a bright kid. When I was young, I was put into a gifted program, but my mom says when I was in fourth grade, the program lost its funding. So I got put back into the normal program. And she says that's when things started to go not so well. So I think that was fourth or fifth grade. Again, I don't really remember much of this, to be completely honest with you, Sean, but my mom says I just got very bored in school and my performance started to sort of go down. I started to really kind of clash with teachers a lot. And I think by the time I got to high school, just really had zero interest in school was, you know, you didn't have it. I didn't have a choice but to be there. But I had no interest in it at all by that point.

Getting into trouble?

I did, but not that much because fortunately by that point I had gotten into boxing. And boxing was, I mean, I think it saved my life because I think it really kept me focused on this goal. I mean, I wanted to be a professional fighter. And even by the time I was 14 years old, I mean, I was training six hours a day.

Wow.

So I was, you know, training in the morning, training middle of the day at school, training when I got home. And so it was my life was basically training and working at the restaurant.

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I mean, I didn't. I didn't socialize. I didn't go. I didn't have time to do anything else. You know, I was working at the restaurant, and I was training.

I mean, you say it. You say it saved your life.

I think so, for sure.

Why do you think that?

Well, because I think, like, I look at a lot. I look at, like, I don't think. I think I had poor judgment as a young kid, which a lot of young boys have. And I look at some of the kids that I grew up with, and I see where they wound up, and I. I just don't know which side of that fence I would have been on. Right. Like, I. I mean, there are kids I grew up with that were 10 years after high school are in jail for armed robbery. You know, you make a dumb decision, like, you can do a dumb thing and change your life forever. And I don't have the confidence to say I would have never been one of the guys that made that dumb decision or been at the wrong place at the wrong time, because I also don't, like, I don't look at myself. I certainly didn't look at myself back then as a leader. I don't think I was a huge follower, but I was mostly just in my own world. But I think if I wasn't in that world, I could have easily wanted to impress one of the older, tougher kids.

And that's how you get sucked into these stupid, stupid things. And it could be stupid things. Like, there was a kid in my high school, and we used to play this game, which was so idiotic, where he would jump into the subway trains and play chicken to see who could get out last. And sure enough, one of the kids didn't get out.

Oh.

And so, you know, you just, like, you see that? No, I wasn't there. But I knew his brother very well because this. The kid that didn't get out was a year younger than us. It was a younger brother, one of our friends. And I. I just think, like, man, there's so much luck involved in not, you know, not. Not ending up in the wrong spot. So. So again, I think for me, boxing and martial arts as well, because I was doing both by the time I was in high school. They just became an amazing thing for me. I. I ended up hanging out with people who were older. Right. Because you're, you know, it's not a place for a lot of kids at the time. Right? This was. You're. I'm hanging out with grown men. So you're sort of seeing these guys who have jobs, and you, you know, you're. You're. I think they were just a good influence on me.

Yeah. Yeah. How far did you take your boxing career?

Well, I was super serious about it. So when I finished, when I was in 12th grade was when I did make a decision to not become a professional boxer. Um, and, you know, it was really because of this teacher I had. So when I was in 12th grade, I had this teacher who really made a big difference in my life. And again, I'm really grateful for that because even though I was pretty good, like, statistically speaking, you have to think in terms of probabilities. Statistically speaking, I was going to wind up, you know, brain dead, right? Like, very few people are going to hit escape velocity in a sport like boxing.

I'm curious one. You said you clashed with teachers, so how did that teacher make that influence on you?

Well, you know, for reasons that I don't know, I still kept taking math. I think I, deep down, kind of liked it. And so he was my math teacher, Woody Sparrow. And so this is, you know, 12th grade, I'm taking math, and I'm actually doing reasonably well. Right? Like, I'm not, you know, top of the class or anything, but I'm. But I'm doing well. And I just like the guy. Like, he's funny, but he's got, like, kind of an edge to him. And middle of the year, one day he says, hey, can I. Can you come in tomorrow morning before class? I said, sure. So I came in and he said, you know, Peter, I heard you're not going to university. And I said, that's right. And he said, you know, I think that's a mistake. But he didn't lecture me, right? He didn't give me the, you know, you're crazy. Not to go to university. He gave me the. He said something else, which was very touching. And he said, look, I think it would be. I think it would be a. I think. How did he word it? I think it would be a waste, because I think you have an unbelievable amount of potential, and I just think you should revisit the decision not to go.

I think you have a real gift for mathematics that you don't quite see yet. But I think, you know, I just think you should be open to the idea of doing something. And there was something about that. I mean, that undoubtedly planted a seed in my mind that over the rest of that year, I kind of changed my thinking, came back for this fifth year of high school to take all of my prerequisites to then apply to go to university and actually set out to emulate him. So he was actually an engineer before he came back to teach math. So I went off to the same university he went to to study both engineering and math.

Interesting. Yeah, interesting. So you went in. Actually, before we go there, I'm also curious. I mean, is a. Is a boxer, is a mixed martial arts guy. You know, I've interviewed a handful of. Of pro fighters, and I'm. I'm always curious, you know, with. With the. With TBIs and all that kind of stuff. What do you think about kids in boxing now?

You know, it's super tough. Like, again, I think about how lucky I am. I only really had one horrible concussion. It was really bad. And I was hurting for about three months. Like, literally, my head hurt for three months. I couldn't turn my head even at that speed. That's how badly I was contused. And so I feel insane gratitude again, like, how many times could my life have ended? And it's really funny, I remember being in the hospital because I spent two days in the hospital after this one, and this neurologist comes in and he's like, oh, and by the way, the worst part of this story, Sean, I was already in university at this point.

Oh, really? Yeah, yeah, yeah.

Like, this was already after I decided I'm not going to be a professional boxer. But I couldn't let go of the drug. Like, it was still. I still wanted to fight. So at this point, I was, like, training, and I was like, I would fight lots of guys in the same day. So on this particular day, I had lined up three opponents for two rounds each, and I'm fighting them at increasing weight. So it was in the fifth round, I'm fighting a guy 25 pounds heavier than me. And I just could not get out of the way of this guy. And I mean, you know, and I. It's. It didn't even knock me down. It was just at the end of five rounds, I was like, yeah, I don't feel right. Let's. Let's call it a day, Mike. So this. This doctor comes in and he goes. He was just apoplectic. He's like, I heard you're a smart kid. Like, what are you doing? What are you doing? Do you understand what this is doing to your brain? And I never thought about it. I was like, yeah, I never really thought about it. What is it doing?

Yeah, that's a really interesting thought. So to answer your question, I'm torn, because I think that boxing teaches you something about yourself, and it's probably true of other forms of fighting. I just don't know. And I did a lot of boxing, obviously, a lot of martial arts and a lot of Thai boxing. I never did mma. I never did jiu jitsu or any of the other stuff that kind of rolls up into what we see today. But I would guess it's true of any combat sport is you learn how to control your fear. You learn what it is like to be alone in the ring with someone who wants to hurt you. I think there's something really valuable about that. Now, my boys both do jiu jitsu. They've been doing BJJ since they could start. I love that they do that. If they wanted to box, I would love it. I just don't know if I'd want them to spar. I'd love for them to learn how to hit, but I also realize if you're not getting hit, you're not really learning how to hit unless you're also being hit. You know, you're gonna develop a lot of bad habits if you're hitting without the risk of being hit.

That said, I just don't think it's worth it. I think I'm happier that they do BJJ and that they're. You know, that their brains are being spared.

If they came to you and they wanted to start boxing or striking, would that be a hard. No.

No, it wouldn't. You know, we have a heavy bag hung up, and every once in a while they're like, dad, show us how you can hit this thing. And I'll hit it. And they'll be like, whoa. Which, by the way, I can only do for, like, 30 seconds. Next. But that, like, that's how bad I am today, right? I can look good for 30 seconds. So I would love it if they would learn. But do I want them in the ring taking hits? I don't think so.

Yeah, it seems like everybody that I interviewed that's in that space, they want their kids in some type of mixed martial arts. But no striking, no headshots. I hear that a lot, pretty much from everybody. And. Yeah, that's interesting. So you go to school. When did you become interested in the medical field?

So when I finished engineering, I was getting ready to go and do my PhD in aerospace engineering, which had become the convergence of my interest in math, and I had done mechanical engineering. And then I had a total change of heart and decided I wanted to do medicine. And so that kind of derailed me because then I didn't have any prerequisites to apply to medical school. And you have to take this test called the mcat. It's like the sat, but for medical school. So I hadn't done any of that stuff. So I had to take an extra year to do it and apply to medical school.

What got your motivation into medical.

Yeah, so it's. It's one of those things where there was an instant when it happened. So there was a single moment where I realized it, but it was predicated on a year of angst. So I don't know which it was. You know, the story about the. You know, the guy hitting away at the stone, and it's like on the thousandth hit, the stone splits, and you realize it wasn't the thousandth hit. It was the 999 before it. It just happened. So I'd say that the year of angst was really something I was struggling with. I was just kind of like. I felt like this tug. Like I wanted to help people, I wanted to work more directly with people. But I really loved. I loved the problem solving and whatnot that we were doing in engineering. But I felt this tug kind of in my heart to do something with people, and I just couldn't figure out what to do. And it's interesting. Like, medicine never actually crossed my mind. So I was. I mean, I had crazy ideas. I was like, should I be a social worker? Which, of course, if anybody knows me, they would laugh hysterically at the idea of me being a social worker.

I thought about, should I be a lawyer? Like, I had all of these ideas for things that I should be doing. And I went and talked to people who did these things. These weren't like, idle thoughts. Like, I mean, I was out there talking with people of all of These professions saying, hey, you know, I'm trying to figure out, am I going to be good at that? Am I going to be good at that? Am I going to be good at that? And medicine never once entered that calculation until one day I happened to be in the hospital visiting somebody and had this experience. And I was like, it just kind of hit me in the face. I was like, oh, my God, Medicine. That's the thing I should be doing.

What was the experience?

So at the time, I was volunteering the whole time I was in college, I volunteered for kids who had been abused. And I was in the hospital visiting one of the kids, and I was in the waiting room, and I was eating my lunch, and another patient, an older woman, came up and sat with me, and she had been shunned by a group of patients at another table. It was kind of weird. I don't know why, but they didn't want her to sit with them. So she came and she sat with me, and we sat there and had a pleasant conversation while I ate my lunch and waited for the nurse to come out and get me to go in and visit the kid that I was visiting. And when the nurse came out to get me, the woman said she. I think she assumed I was a doctor, but then realized in that moment I wasn't. She goes, oh, I should have realized you weren't a doctor. No doctor would sit here and have had this nice conversation with me for this long. And I remember thinking, boy, that's sad if that's true. But it just all kind of clicked in that moment, which was maybe.

Maybe medicine, maybe being a doctor would be the right way for me to apply both my. My interest and love in problem solving and science. But. But with this kind of more human connection.

And then fast forward a little bit.

You.

You left your residency.

Yeah. 10 years later.

10 years later. Why did you. What are we missing in between there?

Well, so then I went to medical school and. And then this. You know, you go to medical school and you decide, what do you want to specialize in? And you don't figure that out until you're in your third or fourth year of medical school. And by that point, I decided I wanted to do surgery. And then you pick a place to go and do surgery. And I wanted to go to the best place. That was the most hardcore place, and that was this place in Baltimore called Johns Hopkins. And because one of the things that made Johns Hopkins so great, and to this day is both the combination of having the high volume of surgeons who do really complicated operations. In this case, operating on the liver and the pancreas for cancer. And at the same time, it's in a really, really rough inner city area. So you get a lot of trauma. And as perhaps grotesque as it sounds, it's really important for surgeons to train in trauma areas because you learn so much about how to fix the human body when the human body is getting shot and stabbed every day. And at a place like Hopkins, I think at the time I was there, it averaged 16 penetrating traumas a day.

Wow. So if you now think about that, I'm on call every third night for trauma.

Wow.

So now think about how many stab wounds and gunshot wounds you're taken care of. You're really, you, you, you know, this is how you learn to have ice in your veins. And it, you're unemotional about it. It's like, what's coming in? What do we need to do? How do we stabilize this patient? Can we fix them? Let's go. And so again, you don't get that experience at all the hospitals. Right? That's, that's, there's there, you know, but, but people who, you know, will, will, will pick programs that really emphasize in that are going to go there. So, so, so I went there and, and really honestly had an. I mean, just had a very special experience. I mean, really can't say anything negative about the place I was at. Right. This wasn't like. I mean, I had amazing mentors there. The surgeons at Hopkins were legends. My co residents were incredible. I mean, I'm sure it's like what you feel like being in the Seals like you are with the best of the best. It's the best 1% of the best 1% that all came to this place not cause Baltimore's a pretty city, but because this is the best training we're gonna do.

But I just, I became really frustrated with the fact that I did not feel like I was moving the needle one bit. And I felt like everything I did was a day late and a dollar short. And it just didn't matter. Like. And that meant like, I felt like it didn't matter on the cancer side. Like you could do the most perfect operation on somebody to remove the cancer, but you didn't get every sellout because you couldn't, you know, they were still going to die 18 months later. And sometimes even on the trauma side, it would be really tragic. You would, you would, you know, you would use 60 units of blood and operate for eight hours to save somebody. And then the next Month, the guy would be out there and get shot in the head. Geez, you know, you would see this. You would see this from time to time where, you know, so I just felt very frustrated, and I just thought the system didn't make sense to me and my wife. I was newly married at the time. My wife said, incredibly wisely, she's like, look, we've only been married for a year.

I've only known you for four years. But you don't strike me as a person who can live in this state. Meaning only two things are sustainable. You either need to fix the system that we're in. So you have all these complaints and grievances about why the medical system isn't right. You should fix it, or you should leave it. But if you sit here and just keep bitching about it like your life is over. And, you know, I spent the next six months thinking about what she said and then just decided to leave.

How long did it take you to kind of cut your emotions off from all that trauma that you were experiencing with your patients?

You mean the actual trauma cases I'm talking about? Like when someone comes.

Gunshot, stab, gunshot, stab, stab, stab.

I mean, sometimes, never. I mean, I had some pretty bad failures. I mean, I'll tell you this, one of my last nights as trauma chief. So I left on June 30. The residency year runs July 1 to June 30. So even though I decided to leave by March, I stuck around for the last three months. So I remember it was like April 14th. Meaning I've got like six weeks left in all of my medical training at that point in time. And I was the trauma chief that night for Pediatric Trauma. And we get a call. It's early in the evening. It's like 7:00 at night. MVA, motor vehicle accident. But no vital signs in one of the two. So it's two. I don't know anything other than it's two kids driving. And one of them seems totally fine. One of them's got no vitals. The one that's got no vitals is coming to my trauma bay. So I go down and this boy comes in and he's got. Maybe I convince myself he's got a pulse. He's got a thready, thready pulse. And now. So we run a code on him, we can't get him back.

I get an X ray, I see that his aorta is a bit wide. You're running through your mind what's going on here? What's going on? Why do I not have vital signs in this kid. Right. Is this head trauma? His pupils are a little bit big, so that means there's probably something wrong with the head. His aorta is a bit wide, though. That means he could have torn the aorta. So when you have blunt trauma, when you have massive deceleration, and in the case of this car, they were. They were. They had the right of way going through an intersection, and some idiot t boned them. So massive deceleration can shear the aorta. So he could be literally bleeding into his aorta. So I have to make a decision. Do I open this guy's chest to try to figure out what's going on? Which, by the way, is not the answer. But, like, I'm. I'm. I don't want to let this kid die yet. And it looks like he's dead. So I keep running the code. I keep running the code. We keep pumping more epinephrine into him. We keep doing everything. And everybody's kind of like, it's my job to call the code to say time of death, call it over.

And I just can't bring myself to do it. I'm like, no, no, no, we got to keep going. We got to keep going. I'm just feeling this overwhelming sense of sadness. And we finally call the code, and I. You know, it's very unusual. Normally you walk out as quickly as possible. Cause they have to get the body out because you have to make room for the next trauma to come in. You don't know when the next one's coming in. So you can't have that. You can't have too much time with a body just sitting there. So they have to cover the body up, get it out, clean the floor off. And there's a mess everywhere. There's. You know, we've put a million central lines in him at this point. There's needles, blood everywhere. And I remember leaving the trauma bay and going into the stairwell and just completely breaking down, which was very unusual. Right. Normally you sort of. You just don't even think about it. But I was absolutely. I couldn't put myself together. And then the nurse came and said, hey, can you go talk to the mom? And I was like, yeah, yeah.

So now the mom and all the relatives are in a room. They only know that they're. Turns out, I realize these are two brothers. The victim who was in the passenger seat is 14. The brother was 17. He's fine, by the way. He doesn't have a scratch on him. And the mom just knows Your boys were in a car accident. And I go and tell her what's going on. And, I mean, it was the most difficult thing of my life. I still remember, you know, and when you're wearing scrubs, they have a little pocket on them. She grabbed on to me and tore the pocket off the scrubs. I'd never had somebody do that. And I spent. I probably spent two hours with them that night. And I was very fortunate that nothing else came in that night. Like, I had the time to sort of be there. And I'm not sure why. I don't know what it was. His name was Malcolm. I don't know what it was about Malcolm's case that devastated me. I also went to his funeral five days later, which I'd never gone to the funeral of a trauma patient before.

I'd been to the funerals of patients, but never a trauma patient. Cause you don't usually have a connection to trauma patients. Right. You don't know them. They come in and they die. You don't know them. But I got to know a lot about Malcolm's life. And at the funeral, when I walked past the casket, I don't think his mom expected to see me. And when she did, she lunged at me, grabbed me, and I kid you not, she grabbed me so hard, she tore the pocket off my dress shirt just as she had torn off the scrubs five days earlier. And it's interesting. I learned more about Malcolm at that funeral that day than I, you know, obviously, would have ever imagined knowing. And it's. The story is just even more tragic when you realize what an amazing kid he was and what he meant to his family. It's interesting. So he, you know, so a relatively poor black family, and he was this incredible student, and he was going to a really special school because of his exceptional abilities. And that's why his brother was actually driving him, like, you know, he couldn't go to the local public school in inner city Baltimore.

He was going to a school in the. In the northern part of Baltimore. And he was, you know, he was the jewel of his mom's life. Man.

Man. How do you, you know, as a surgeon that the. Treats that much trauma and sees that much death? I mean, how do you disassociate?

I mean, I could ask you the same question.

You don't.

Yeah.

How long have you been married?

We're 21 years now.

21 years. Congratulations.

Thank you. What about you?

I've been married for five years. So what's the secret to a successful marriage?

Pick the right person, I think is literally the single most important thing. I mean, I think that's not sufficient. Right. You still have to do work, but, but if you don't get that piece right, I think it's harder. And there's no one right person. That's obviously sort of silly. So there's like an operating window, I think, in which you can marry people. I think I just got really lucky. Like, I think that's the theme of my life is just obscene luck. But I just didn't understand at the time how lucky I was to meet this woman and how much she could kind of tolerate all of my challenges and all of my focus and how relentless I could be and how difficult I could be. And so it took me a few years to figure that out, but once I did, yeah, I just think, like, I get it. I get what you see these people that are in their 90s that have been married for 70 years and you hear them talking about each other like they can't imagine living without each other. And you think, really? I mean, he's that special, she's that special.

But, but, but now I get it. Now I get it. Now I understand, you know, and my wife will tease me all the time and she'll say, you know, you know, she'll say, oh, you sure you don't want like some young, hot, 20 year old wife? And I'm like, absolutely not. You know, I, I, I, you know, cause it's, I think once you get to a certain point and you've been through enough tough stuff together, you really understand what it's about.

How'd you guys meet?

We met at Hopkins. We met two days after nine. Eleven actually, because we were still kind of in lockdown in the hospital at the time. It wasn't clear what the damage was and how like would we still need to be on standby for bodies. And of course it turned out that that wasn't the case at all.

Interesting. So, wow. So did you treat a lot of those victims?

No, no, that's the point. Like, nothing came up from the Pentagon, nothing came down from New York. I mean, people were incinerated. There was nothing to treat.

Geez. Geez. Well, Peter, let's take a quick break and then when we come back, we'll pick up with your medical career. While we may have won this election, the fight to restore a great nation has just begun. Now is the time to take a stand. And Patriot Mobile is leading the charge. As America's only Christian conservative wireless provider, Patriot Mobile offers a way to vote with your wallet without compromising on quality or convenience. Patriot Mobile isn't just about providing exceptional cell phone service. It's a call to action to defend our rights and freedoms. With Patriot Mobile, you'll get outstanding nationwide coverage because they operate on all three major networks. If you have cell phone service today, you can get cell phone service with Patriot Mobile with a coverage guarantee. But the difference is every dollar you spend with Patriot Mobile helps support the first and Second Amendments, the sanctity of life in our veterans and first responders. Switching is easy. Keep your number, keep your phone or upgrade. Their 100%. US based customer service support team will help you find the perfect plan. Right now, go to patriotmobile.com SRS or call 972-patriot and get a free month of service with promo code srs.

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Foreign Back to Where were we? We were. Oh, we were talking about secret to successful marriage and you're leaving your medical residency and you end up at McKinsey modeling credit risk. How did that happen?

Well, when I wanted to leave medicine, I wanted to get as far away from medicine as possible and I wanted to go and get an mba. But I was in so much debt that the thought of more debt to go to business school for two years was not very appealing. I met somebody actually When I was on call one night in the er, another resident, and they told me about this place called McKinsey. So I learned about it. Sounded like a great place where basically you get paid and you get to learn all the stuff you would learn through an mba. And so that's what I. That's what I did. And so I ended up out on the west coast and working on sort of math problems again, but in the. In the sort of financial banking section.

And then you wound up back in.

The medical industry eventually, Yep.

How did that happen?

Initially, just through my own kind of interest in trying to figure out my own health. You know, once my daughter was born, when I was 35, I, you know, thought about, hey, I gotta. You know, I'd been always interested in performance, obviously, and, you know, you mentioned it swimming and all sorts of crazy escapades, but. But had never really thought about health per se, and so wanted to, you know, just better understand my own risk of initially cardiovascular disease, because that's the disease that runs most rampant in my family. And as I just became deeper and deeper in terms of my interest in understanding that, I wanted to start applying it to help others. And so I began to slowly sort of start working with other patients because I'd never let my medical license lapse. So the one thing someone gave me advice when they left, they said, hey, I know you think you're done with medical medicine for the rest of your life. Just take the test every two years, keep your medical license. You'll be grateful you did. Which was sage advice, because I think if you let the thing lapse, it can be a bit of a grind to reacquire a medical license.

So that's kind of how I kind of slowly came back into it.

And you have three kids?

Yeah.

How old are they?

Sixteen. Ten and seven.

Sixteen, 10 and seven. Any. Well, actually, I was gonna ask for fatherly advice, but how old are yours? Mine are one and three.

Okay, we're in it.

We're in it. But, you know, being who you are, and you're a businessman, you're an author, you're a podcast, you're a medical professional. I mean, you've got all these things going on. You got three kids, successful marriage. How do you balance all that?

Well, you have to make some sacrifices, right? So there are just certain things I don't do. I don't have a lot of idle time, and I think that idle time can be beneficial. Like, I think there's value to doing nothing. And unfortunately, I don't have A lot of nothing time. I also don't have a lot of hanging out time. Right. And, and, and, you know, I, it sometimes means I come across as a little bit aloof. And, you know, when people say, hey, you want to get together? My answer is usually no. No offense, it's not you. But like, on the hierarchy of work and family, like, I just don't have the time, right? I don't. Everything I do has to be, has to be somewhat measured. And so between the time I make for exercise and hobbies and spending time with my kids, and like, once a month, I want to have a special day with each of my kids individually. Right?

Once a month.

Once a month. So that means, like, going away, for example, like, you know, take my kid to Disneyland, if that's the thing they want to do. Take my daughter to LA if she wants to go shopping, or take, you know, my son is really into Harry Potter, so we're going to go to Harry Potter Land. Like, I want to have a real special day with each of my kids once a month. So when you start, I mean, there's only 30 days in a month, like, that's one of them gone, right? If I want to have a date night with my wife every single week, that's one night a week gone. And I say gone. Not that it's a bad thing. I'm just saying, like, there's only 168 hours in a week and I'm going to sleep for this many of them and I'm going to exercise for this many of them and I'm going to work for this many of them. There's not a lot of hours left, so that's probably how I get away with it, right? I don't watch tv. I don't know. I don't know the last time I watched anything on TV that wasn't Formula.

One, like Formula one guy.

Formula One's the only thing I pay attention to. I have not watched a single football game, literally not a single game of football in I don't know how many years now.

Yeah, and you are very similar with the TV aspect. Do you race?

I drive quite a bit on the track, but not as much as I used to or not as much as I would like to. So in an ideal world, I should be on the track two to four days a month. That's not happening right now. So I probably spend more time in the simulator now. And realistically, if I'm on the track this year, I'll probably do 16 days total. And the Whole year on the track.

What are you driving?

My favorite cars are formula cars. So, like a Formula 3 car. But also I love, like, Porsches and, you know, all sorts of cars.

Nice. Nice. Well, let's move into medical 3.0. What is it?

So it's a term that I use throughout the book to describe kind of an evolution of medicine, right. So I contrast it with medicine 1.0, because you can't have a 3.0 if you didn't have a 1.0 and 2.0. So maybe it's easier to kind of explain what 1.0 was, what 2.0 was and is. Because 2.0 is the dominant system of medicine today. And then what am I proposing as 3.0 for where we go? So medicine 1.0 was medicine through all of human history, basically until the end of the 19th century. And so for the longest period of, you know, for hundreds of thousands of years, whatever we thought of as medicine, this 1.0 system wasn't a scientific thing. Right. It was ideas that were based on beliefs that we had at the time that I think were understandable, given that we didn't have a scientific process. So it meant that diseases were believed to result from the gods or from bad humors or from these sorts of ideas. And therefore, the treatments were usually pretty ineffective. You know, it wouldn't be uncommon for them to bloodlet people if someone had a fever or to bore a hole in your head if you had a headache.

I mean, things that we would look back at today and say, that's crazy. Well, yes, but they didn't know any better, and that was medicine 1.0. And, you know, people lived pretty awful lives. You know, I think if anybody. If anybody's feeling sorry for themselves, which I think we're all prone to, myself included, we should just remind ourselves that we weren't born a thousand years ago. You know, like, how lucky to just be alive today if you're still feeling sorry for yourselves. How lucky if you're listening to this and you live in the United States or you live in, you know, some part of the world where, you know, you have the freedom we have. So now you think about how, like, people just died all the time, right? They died of infectious diseases. You know, there was probably a 30% chance that a woman was gonna die during her lifetime giving birth. Just astonishing hardship. All of this changes about 140 years ago with a handful of seminal improvements. One is a real codification of a scientific method. Remember, science is a process, so I really get Frustrated when I hear people talk about science as a thing.

It's not a thing. It's a process. It's a way of thinking. It's a way of making observations, taking guesses as to what it is that is accounting for the observation, designing a hypothesis that can be tested in an experiment, conducting an experiment and measuring the results of the experiment against what would have been predicted by the hypothesis. And then if necessary, revising the hypothesis and coming up with better and better theories. That's it. That's what science is. Everything I just said is all you need to know. That's the scientific method. And that didn't exist. That is a man made creation. Very important to understand that it's a brilliant creation. I would argue it is the single most important creation that allows us to exist today. It allowed us to figure out that washing your hands was a way to prevent spreading disease. It allowed us to figure out that there were organisms that we can't see with our naked eye, like bacteria and viruses that are killing us. It allowed us to create medications to treat those things. So just on the basis of those few things I said, we basically doubled human lifespan just by figuring out how sanitation, addressing infant and mother mortality, treating infections, all of these things had a huge difference.

That is what I call medicine 2.0. Medicine 2.0 was heralded in with that discovery. Medicine 2.0 basically says, look, we treat a disease when we see the disease. And the playbook for medicine 2.0 again has been really successful for acute conditions. Trauma is another one, right? Like think about what a soldier in theater today can survive relative to what they could have survived in World War I or World War II, especially World War I and even the Civil War. Let's go back if you want to make it a medicine 1.0 to medicine 2.0. Consider a civil war versus soldier today. Totally different experience in terms of what's a survivable injury. Again, the advances in trauma and critical care are insane. The problem is those things have not extended to life. Life extension vis a vis chronic diseases. So most people that are listening to us right now are gonna die from basically one of four things. Cardiovascular disease, including heart attacks and strokes, cancer, dementing diseases and metabolic diseases, type 2 diabetes, fatty liver disease. Those things that's literally like 80% of people listening to us are gonna die from one of those things. Dementant diseases being Alzheimer's, Alzheimer's, vascular dementia, other neurodegenerative diseases like Parkinson's disease and things like that.

So those are all chronic Diseases. And we have not made great progress on any of them, with the exception of cardiovascular disease. We're doing a much better job on that. People are definitely getting heart attacks later in life, and you're more likely to survive your first heart attack today than you were 25 or 30 years ago. So 30 years ago, roughly 2/3 of people would not survive their first heart attack. Today, slightly more than half will. But I would still argue that all of these results are kind of unacceptable. Right. And that we should be able to do better. And so now to your question. Apologies for the ramble. The first and most important pillar of medicine 3.0 is you have to be able to be better at treating chronic disease, because chronic disease is what's going to kill us today. And again, this is a privilege, right? We've done so well at treating acute diseases that we've now earned the right to have to focus on chronic diseases. But the current medical system was not designed for it. The economics of this system aren't built around it. And again, this is not a conspiracy theory.

You get all these sort of health influencers that want to turn this into a Big Pharma conspiracy theory. No, it's not a conspiracy theory. It's simple economics. You have a billing system that is predicated not on keeping people sick, but on treating people when they get sick. I get so frustrated when I hear people say, oh, Big Pharma has the cure for cancer. They just don't want it out there. They want you to be sick. That is hands down the dumbest thing I've ever heard. If Big Pharma had a cure for cancer, they would happily profit on it all day long. The bottom line is cancer is really, really, really hard to cure once it's taken hold. The far better strategy to address cancer is to catch it early or prevent it altogether. And that's not in the purview of pharma. They're not in the business of doing that any more than the guy who runs the car wash is in the business of making me dinner. They're different businesses. So medicine 3.0 has to come up with a better way to treat chronic disease. And though I won't get into all the details, but I write about it extensively in the book.

You can mathematically prove that the way to treat chronic disease is to delay its onset. Those are mathematically equivalent. So you want to live longer without disease, not live longer with disease. So medicine 2.0 aims to keep you alive longer with chronic disease. Medicine 3.0 says that method will fail. You have to delay the period of time before someone gets a disease. The second big principle of medicine 3.0 is you have to treat this thing called healthspan as much as you treat lifespan. So lifespan is the thing that I think most people intuitively get is like, how long you live. Right. Are you gonna, you know, if your parents are still alive, you could say, yeah, my, my parents are 85 and 80, and hopefully they're gonna live another five years. And that's their lifespan. But there's this thing called health span, which is not as easy to measure, but is more important, which is what's the quality of their life physically, cognitively and emotionally. And so how do you preserve and maximize health span? This is another very important principle of medicine 3.0. Medicine 2.0 does not acknowledge healthspan beyond a very cursory way to describe it.

But there's a saying which I'm sure is true in the military, just as it's true in all of medicine and business. What gets measured gets managed. And in medicine 2.0, you manage to lifespan, that's the metric everybody's focused on. But in medicine 3.0, you have to pay just as much attention to quality of life. And if you manage to that, how much muscle mass do you have? How strong are you? What's your VO2 max? What's your reaction time? What's your cognitive performance? What's the strength of your relationships? That's part of emotional health. All of those things figure into the quality of your Life. And Medicine 3.0 says we should be managing to those just as much as we manage to life expectancy.

Interesting, interesting. So it sounds like more of a preventative.

It's preventive, but it's also very proactive and it's much more broad in its focus. It's not just about how long can I keep you alive, it's how long can I keep you thriving?

So what are some of the. Let's go down. Each. You'd mentioned, I believe, three pillars, but, you know, four. Did you mention four chronic diseases that we're all gonna die from? Most people are gonna die from. Let's start with cardiovascular.

So it's the leading cause of death for in the United States, it's the leading cause of death globally, and it's the leading cause of death for men and the leading cause of death for women. So even though I don't think it gets that much attention because maybe because it's so common, we just sort of tune it out a little. Bit we can't Forget, you know, 19 million people a year globally are dying from cardiovascular disease. Now this is certainly tragic and ironic given that of the four chronic diseases, it's the one that A, we have the best understanding of and C, we probably have the best treatments for. So, you know, we can come back to metabolic disease because I think a lot has changed there. But we certainly understand what the drivers of cardiovascular disease are, and there's several, right? So lipids, blood pressure, smoking, poor metabolic health, those are the big, big, big drivers, right? So if you're insulin resistant, if you have high blood pressure, if you have high, what's called apob, which is a particular measurement of lipids, if you smoke, those things are going to drive your risk through the roof.

There are people who can certainly get away with having one or two of those things not optimized. But if you're in the business of trying to prevent the disease, you want all four of those things fully optimized. Some of those are purely behavioral, some of those are done through medications. We talked about blood pressure as an example. Lots of ways to control your blood pressure without pharmacology. But if you need pharmacology, it's also pretty easy to manage it that way so that, you know, really it shouldn't be the leading cause of death. It just, it just simply shouldn't be. But most people don't have the right timeline on it. They don't realize how long this disease is brewing. So how old are you?

42.

Okay, so you know, the probability that a 42 year old's arteries if, let's just say tragically you died in a car accident tomorrow, if they did an autopsy on you, the likelihood that your coronary arteries would look perfect is very, very low. We know this because during Vietnam they did autopsies on all these young men that were 18, 19, 20 years old, who obviously were killed in combat, so had nothing to do with their hearts, and they did not have perfect coronary arteries. They all had some evidence of disease. And those guys were not gonna die of heart attacks for another 40 or 50 years, to be clear. But what it showed us was how long it takes for this disease to progress below the naked eye. So in the instant that a person has a heart attack, there's an enormous and abrupt change with clotting factors and all these sorts of things. But all of that is precipitated by decades of buildup. And by buildup, I mean sort of impossible to see. Processes that eventually can become visible on certain elaborate Scans. So we do want to start preventing this stuff early by managing those four variables.

And if we do, I think we get to take that one off the table.

How do you start to manage them?

Yeah, so again, you look at each of those risks individually. So first someone's smoking. If they are, I want them to not smoke. And we're going to do whatever steps we have to do to get them off cigarettes. What's their blood pressure again? If someone's got elevated blood pressure, first line therapy is not to turn to medication. It's actually to look at exercise, sleep, and weight. Those three things can fix blood pressure in many cases. But if it can't, the amount of medication we have that can address blood pressure without inducing symptoms. Because that's the other thing you always have to think about. Right. Anytime you're giving somebody a medication, you have to be able to do it in a way that it doesn't create another problem. And a lot of the early generations of these drugs, they cause problems. You know, they'd make you feel horrible in some other way. So if your choice is walk around with high blood pressure, even when you've corrected for body weight, exercise and sleep, or don't, you're better off fixing it, even if it means taking medication. Metabolic health, I think, is the toughest one to fix, truthfully.

And it requires everything from being an energy balance, you know, doing the right kind of exercise. So the right balance between exercise that generates muscle mass and exercise that generates the ability for the muscles to soak up glucose. That's kind of one of the important functions of the muscle, besides the obvious structural components. But the muscles are a huge reservoir for glucose. Putting glucose into muscles is a super important job that drives so much of our health. And then the fourth one is managing these lipids. So this APOB marker, which is a very simple blood test, measures the total concentration of all cholesterol carrying molecules in the body that are harmful. So not all the molecules that carry cholesterol in the body are harmful, but a subset of them are, and that's how you measure them. And again, that can be addressed through diet. But if it's not, again, you want to lower those things pharmacologically.

So what are some things that people can do just right off the bat to better their health, other than smoking?

Yeah, so that's a great one. Right. So if you're, if you're a smoker, I think. I don't think there's anybody out there who's smoking who thinks it's good for them. So really, the challenge there is not the what do I do? It's how do I go about doing it? How do I go about a smoking cessation plan? Which we could talk about another. We can talk about that as much as you want, by the way, because it's a topic I'm very interested in.

Are we talking just cigarettes? Are we talking cigarettes, cigars, marijuana?

So cigarettes are the lion's share of this problem because of just the volume, right? So if you're a cigar smoker, you're probably smoking like, first of all, a lot of cigar smokers aren't inhaling the smoke all the way into their lung. And so it's just generally not posing the same risk. It still is risk, but nothing's probably gonna be the risk of taking 25 cigarettes a day and smoking them, Right? So even people who are smoking weed are not typically smoking nearly enough to get there. Now, when you get into nicotine replacement products, you want to always be able to differentiate them into with and without tobacco.

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So if a nicotine replacement product is derived from tobacco like snooze, it still carries a ton of risk, nowhere near as much risk as a cigarette. So cigarette is still the A plus risk. But if you're consuming snooze, you're still getting a lot of the carcinogenic risk. It's just going to be subject to your mouth as opposed to your lungs. So when you want to get somebody off smoking, you want to create a real awareness of what they're doing. You want to understand. And so typically, the first thing we'll have people do is just journal what. When is it that you pick up a cigarette? What happened that made you want to pick up the cigarette? This is, by the way, this will work for any habit, right? If you're trying to understand why you're eating so much junk food, let's just start with a few weeks of noting every time you go into the pantry for Pringles, what predisposed you to do that? Was there something stressful? Did you have A thought about something. Were you bored? Were you actually hungry? What created the urge? Another one of the things you do is you start disconnecting the urge from the behavior.

So let's say you're a smoker. We would say, hey Sean, every time you feel this urge to go out and get a cigarette, I want you to not do it, but set an alarm for 15 minutes and then go out in 15 minutes. In other words, I'm not going to stop you from smoking. I'm just going to uncouple the urge from when you do the thing. So that becomes important. Nicotine replacement is a very important part of smoking cessation. There are lots of ways to replace nicotine. Right. You've got little patches, I mean little pouches there. I've got my toothpick here. We've got patches, gum, all sorts of ways to go about doing it. Each of them has their pluses and minuses. I did a whole podcast on this that, that, that gets into the itty bitty nuances of this. But the bottom line is nicotine replacement. Very, very powerful tool because nicotine, if derived from a clean source like a synthetic nicotine, it doesn't carry any of these cancer risks. At least we can be very confident that that's true. Certainly not from a lung cancer perspective. There may be other risks. So we should be mindful about how much nicotine we do consume.

But it allows you to deal with what the addictive piece was. And then the final thing is understanding the oral fixation that a lot of people have with a cigarette. By the way, I think that's why kind of the nicotine toothpicks are kind of nice is for many people it's just, it's a bit of an oral fixation with, with a, with a nicotine containing thing. There are also different classes of antidepressants that can be very helpful with people that are quitting smoking. So we'll put that aside because it's self evident that one should not quit, that one should not smoke. But the sometimes to how to do it is, is easier said than done.

Now is there any way to reverse this? Is there any way to, to clean up your arteries?

There is.

If you were a smoker.

Yep.

How do you do that?

Well, when it comes to smoking, we know that after a certain number of years, depending on how long of a smoker you were, your risk of heart disease and cancer will return to baseline. It will, it will, yeah. Now again, you might not get there because depending on how long you smoked, it could be 30 years before you return to baseline. So if you're a 50 year old who's quitting smoking and you've been a pack a day smoker for 40 years, or, you know, say 30 years, you might not make it to 80 without some event. So we still act with enormous vigilance in people who are former smokers. In our practice, we treat former smokers and smokers identically when it comes to cancer screening, because even though we know the risk is coming down in them, we just assume it's still quite high. And so we will still screen them very aggressively for, you know, every cancer that we can, even maybe against the advice of sort of medical authorities in terms of how aggressively we'd look at it. The same is also true for cardiovascular disease. We do see that over time, that risk will return to the baseline risk.

But remember, as you're aging, what's happening to your baseline risk? It's going way up. Age is the single biggest predictor of risk for both cardiovascular disease and cancer.

Okay.

Yeah. So you never want to escape the fact that even though you're quitting and that's driving risk down, age is driving it up. So you never really want to take your pedal off the metal when it comes to prevention.

So what are some of the other things you can do to get back to baseline?

Exercise is very important. Again, the benefits of exercise when it comes to brain health, metabolic health, heart health, are probably the most obvious. I think when it comes to cancer, it's less obvious. Of all the four diseases, I call them the four horsemen in the book, I think cancer is by far the one we understand the least in terms of what's driving risk. So we know that metabolic disease drives risk. So obesity and type 2 diabetes clearly driving risk. We have some ideas as to why, but beyond that and smoking, we don't have a great sense. And I don't think there's anybody who's listening to us right now who can't relate to the idea that otherwise completely normal, healthy people still get cancer. Right. I'm sure, you know, people who are 40, 50 years old, picture of health and they still get cancer.

Scares the hell out of them. It's like every day a text comes in, my mom's got cancer, I've got cancer, my kid has cancer, my aunt has cancer, so and so died of cancer. I mean, it scares the hell out of me.

Well, and I would say this, once you've got your house in order, health wise, it's the biggest risk because you can drive the risk down of metabolic disease, of cardiovascular disease, and even of neurodegenerative disease, especially dementing diseases. We can drive these down. People often ask me, Peter, your whole life is this longevity thing. How are you gonna die? And I say honestly, like, it's gonna vary by decade. But if you said to me in the next decade, if you had a crystal ball that said, peter, you're not gonna make it to. I'm 52, you're not gonna make it to 62. Why? There's really two things. It's cancer and accidental death. You know, I'm gonna, I mean, I'm either gonna get cancer and succumb to it, or I'm gonna die in an accident. That would be 90% of what would kill me in the next decade. Okay, so. So you're not alone, right, in feeling that way. That's a rational fear. Fortunately, given your age, you're 42, your 10 year mortality from cancer is still very low. It's probably in the 2 to 3% range, but that's not zero. Like.

Well, you know, it also bothers me because you see all these weird cancers, you know, coming up from, from being overseas.

Yep. I think some of the stuff you've been exposed to, I'm sure.

Yeah, I mean, I don't even know what I've been exposed to, but there's all these weird cancers nobody can explain. Just had this guy on, Chris Fettis, who was, we were talking about the jammers that used to jam the frequency for IEDs and stuff. And maybe sitting under that thing, he says there's been studies out there that have said the. Definitely increases the risk by a pretty large amount. And I mean, it's. Man, it's just every.

Yeah, I mean, I think the only thing you can do is you sort of have to decide, am I willing to trade that anxiety for another anxiety? Because you're gonna have to deal with some anxiety. So anxiety one is I'm just gonna worry about it, but I'm not gonna go looking. Anxiety 2 is I'm gonna do everything in my power to screen and look for this, but I'm very likely gonna find a bunch of things that aren't cancer. Those are called false positives. So which of those, and this is a very individual decision, but which of those gives you more stress? Are you more stressed just sitting here worrying about it, or are you gonna be more stressed if we turn over every stone, screen the hell out of you, and find a bunch of things that ultimately will not be cancer, but we're gonna have to chase them down. Which one of those is more anxiety provoking?

I don't know. You know me, I don't know. Me and my wife have talked about doing the pre cancer stuff. I've had blood work done. I know there's some kind of imagery that you can do.

Yep.

You know, and we were signed up to do it. And then my wife said, hey, you know what happens? What happens if something does pop up and they say, oh, give God this much time to live? Then how do we treat each other during that time? And that's something I never thought about. I was like, shit. You know, that's. It would be a whole new dynamic. You'd be thinking about your future without that person. That person would think, oh, I'm holding you back in life. And I mean, so I don't know. We haven't done it for that reason. Like I said, I did do the blood work and she's getting the blood work done and so far, you know, so good. But I mean, what do you do?

Do you get well again? It's a very personal decision, just like we were talking about with the vaccines earlier. There's not a right answer. And if every, every single patient I'm talking to, I'm not trying to impose my will on them or my beliefs or even what I do. I want to help them understand probabilities. This is the probability of you getting any of these types of cancers. This is the probability of this test that we do giving a false positive. This is the probability of it giving a false negative. And again, we know all of this stuff. We know for every test we do, there are these two mathematical terms. One is called sensitivity and one is called specificity. So if you do that liquid blood, so what you're referring to, I assume, is a liquid biopsy. So it's a blood test that's doing a pan screen for cancer. That test has a sensitivity, which is the probability that if you have cancer, it will pick it up. The sensitivity for a liquid biopsy is very low. For a stage one or stage two cancer, it's probably on the order of 30% for all cancer.

That's it.

That's it. For all cancers, it's probably on the order of 50% sensitivity. Conversely, the specificity, which is the probability that the test comes back negative if you are free of cancer, is very high. The specificity on those tests typically runs about 99.5%. Now, when you know those two numbers, sensitivity and specificity, and you know the probability that you have cancer out of the gate. What's called the pretest probability, which says you're a 42 year old man, you don't smoke, but maybe you have a slightly higher risk because of your exposure to chemicals, blah, blah, blah, blah, blah. Your pretest probability is 3%. Knowing the pretest probability, the sensitivity and specificity allows us at any point in time to calculate what's called positive and negative predictive values. Which means if this test comes back positive, how likely is it you have cancer and it's going to be very low. Okay. Okay. The whole takeaway of that whole spiel is the PPV or positive predictive value is going to be like 10%. So even if that test came back positive, it's a 90% chance you don't even have cancer.

Okay.

The negative predictive value is going to be very high. The negative predictive value is going to be above 99%. So if it comes back negative, you can feel really comfortable. Negative comes back positive. And this is what I got to earlier. I don't even let people do these tests if they're not willing to live with the consequences of a false positive because the likelihood of that happening is actually pretty high.

Well, what if you do get a false positive? What then? What happens?

Well, I'll tell you, I'll give you a really horrible story of a false positive. Was just talking to somebody the other day who went and got a whole body MRI and it found something in his thyroid that looked a little suspicious. And to be clear, the thyroid gland is notoriously difficult to image. Notoriously difficult. It is so glandular and so prone to overrepresentation of cancer that we see, we see false positives all the time in the thyroid. I just tell patients, 10%, 20% chance we're going to see something in your thyroid. In this case, saw something in his thyroid. His doctors recommended a thyroid ultrasound and a biopsy. So they did the ultrasound, they did the biopsy. Now normally at that point, that's the end of the line. The thyroid is really easy to biopsy. You can feel it under an ultrasound. It's like shooting fish in a barrel. Pull a couple cells out, no cancer, you're fine. Sorry for the inconvenience, we'll see you in a year. But in this case, when they did the biopsy, they're like, it might be cancer. We can't fully tell. And they recommended removing the half of the thyroid.

So they did. Now they did the surgical operation, they took out his half thyroid and it came back. It was Totally fine. Now, is this a life changing surgery? No. Can you live without half your thyroid? Yes, but that's an example of what can go wrong. Now how do I choose to live with that degree of uncertainty? Personally, because of my risk appetite, I make the decision to screen. I screen myself very aggressively. So I do get a whole body MRI every year. I'm very aggressive with the frequency with which I do colonoscopy. I do liquid biopsies every year. I'm religious with my skin exams. And again, some of these things are low risk. The risk of a skin exam means I'm losing a couple moles I didn't need to lose, who cares? But a colonoscopy is a huge risk. You know, I shouldn't say huge. I mean, it's just a very non zero risk. But again, I consider it a bigger shame to get colon cancer and to miss a colon cancer, something that's, you know, third leading cause of cancer death. Right. I want to make sure I'm not going to succumb to colon cancer.

So, you know, I don't have an answer for you, but I could walk you through every number and let you make the best answer for you.

What age should people start getting screened?

Probably depends a bit on family history, which really speaks to risk. Colon cancer is an easy one to talk about. So it used to be that traditional screening for low risk individuals was 50. I'm very grateful to see that that's been lowered to 45. So that means now people can get insurance to cover them five years earlier. And I think that matters a lot. Personally, I would lower it to 40, although I understand maybe on an economic basis why it doesn't make sense. But as an individual thinking about yourself, look, I still think 3 to 4% of cancer, colon cancer deaths are in people younger than 40. That's a staggering statistic. People just don't think of young people getting colon cancer, and yet they do. So I would say somewhere between 40 and 45 is probably the right time for a person to get their first colonoscopy. Unless they're high risk, in which case you want to be treated earlier than that. So if you person have ulcerative colitis or Crohn's disease or a family history of colon cancer, things of that nature, I would be doing it even sooner.

Okay, rewind back to cardiovascular stuff. You had mentioned getting back to baseline. How do we know when we're back to baseline?

Well, unfortunately you can't. And to be clear, baseline. I said baseline risk. So you're never going to take your coronary arteries back to what they looked like when you were 10 years old. Right. So what we really aim to do is stabilize the progression of atherosclerosis. And so depending on what sort of screening modality is used to measure, and the most common one that's used is something called the calcium score. But there's a more advanced test called a CT angiogram. So they're both CT scans, but the calcium score just runs over the body, doesn't put any contrast in and is just looking to pick up the light of calcium. It's not a very granular test, but if you have any calcium in your coronary arteries, we know that's bad. That's not a good test to measure progression because it's not a very accurate test and it can easily be over interpreted. So if a person's calcium score is 100, if you had a calcium score of 100 at the age of 42, that's a four alarm fire. Even though 100 is not a very high number, that number could easily be 4,000. At the age of 42, it should be zero all day, every day.

But if it was 100 and then five years, then we started treating the heck out of you and five years later it was 130, that would in my mind, not constitute progression because of how crude the test is.

Okay.

Now if they use a more granular version of that test called a CT angiogram, it's a more high resolution CT scanner where they use intravenous contrast. Now you get to look more at the coronary arteries and there you can get more subtle descriptions of what's going on. But the truth of the matter is when you're treating the causal risk factors, we don't tend to fixate on the imaging as much as we fixate on function and the reduction of risk markers. So if you showed up at 42 with a calcium score of 100, there's no doubt in my mind that at least one of those four factors is out of whack. We're gonna fix it. We're just gonna fix it. Non negotiable. And in five years, even if your calcium score has gone up a little bit, we are still very confident we've halted the progression of the disease.

Okay, okay. Back to cancer preventatives. I've talked a lot about this with other health professionals on the show and, and it seems like plastics, sugar, what else? Single ingredient foods. I mean, do you have any? Do you have any?

Again, we can talk about what is absolutely known, what is unambiguous, is smoking, Obesity, diabetes are driving the majority of what we see as preventable risk.

Okay.

So that's the only thing that I would say we know with a very high degree of certainty.

Once again, when you're smoking, smoking cigarettes.

Cigarettes, cigars, mostly cigarettes. Okay, yeah. Now cigars, even if you're not inhaling, you're still increasing your risk of oral cancers and things of that nature. But yeah, when we talk about a person who smokes a cigarette that they're inhaling, that's increasing the risk of many forms of cancer, not just lung cancer, although it's increasing your risk of lung cancer geometrically. So if you're overweight or obese, if you have type 2 diabetes, if you smoke, any combination of those things is increasing your risk of multiple forms of cancer. They're not all the same, by the way. So the cancers that are predisposed or the ones that risk is going up dramatically for type 2 diabetes and obesity overlap with some of the lung cancer. But there's some different ones as well. Everything thereafter that we are at a lower level of certainty. So I did a lengthy, lengthy deepest deep dive I've ever done, certainly top three deep dives ever done in my life, into microplastics on a podcast a few weeks ago. And I can tell you that the evidence that microplastics, PFAS chemicals, PM2.5s, are causing cancer, PM2.5 are sub 2.5 micron particles in the air that we inhale.

The evidence that they can cause cancer is modest, it's not very strong, but it's also shouldn't be ignored. Right. I wouldn't throw it out and say, ah, come on, it's all fine. The question is, what do you do with that information? Like, how hard should one work to avoid all of these things? Because it's impossible to avoid them, period. That's, it's, it's actually that we can't. We couldn't imagine a scenario whereby a person could completely be free of microplastics, even if you said something as ridiculous as I'm going to move to the Antarctic. But you wouldn't be able to, because the protective clothing you would need to prevent you from dying in that environment would expose you to microplastics. So we're going to be exposed to microplastics no matter what. But there are a bunch of things you can do to like, either inconvenience yourself in time, money, some other variable, and reduce it a lot. So you Know, I actually made a video kind of recently about this which is like, what's my 8020 view of how to do this? And it's some obvious stuff. So one, don't store food in plastic containers. Just so if the restaurant's trying to give you your food in plastic container, just don't take it home.

At home, throw out your plastic storage containers. Splurge on Amazon for the glass storage containers and just use those. Don't heat up anything in plastic. So my kids, because they still throw cups, will still have a few plastic cups. I'll put cold milk in there, but I would never put anything hot into there. And frankly I can't wait till we're kind of done with plastic cups in general. One big splurge I did was I got rid of my drip coffee machine which just had plastic all over it. And I swapped it out for a machine that is all glass and metal. So it still makes a drip coffee. But the water is. The hot water is only exposed to metal and glass. So I'm. Which again, anytime hot water was exposed to plastic, you're really increasing your risk. So that's a, that's. But you know, that's an expensive coffee machine. But it's a one time cost. Another thing was, and we had already done this before, but I do think this is a worthwhile investment for people who can afford it is putting in a reverse osmosis water filter in the home and drinking out of that huge source of microplastics and other chemicals that you want to avoid.

Another thing that you can do, which again is a big cost and this is not something everybody necessarily should do, but especially if you're indoors a lot is moving your air filtration system up to HEPA level. Okay, again that, that requires a. That's a, that's a cost. There's a real cost in doing that. Not in the filters themselves. They can be relatively inexpensive, but in the H Vac machines that need to blow them are pretty expensive. So standard residential H Vac units typically aren't powered to do it. So you'll have to upgrade them. Little things like. Sounds silly, but like I don't take a plastic bottle into the sauna. I use a glass bottle. I don't even keep a plastic lid on it. I just don't want anything heating up. Plastic. Those are, those are. Oh, I switched out my water bottles in. I used to ride my. If I'm riding my bike outdoors, you know, cyclists have plastic water bottles. I just found a company that makes steel Ones. So those are kind of the big things. So again, a lot of it's a single upfront big cost. The water bottle is like 40 bucks, which is a total ripoff, but whatever.

So single big upfront cost, but then after that you're kind of done thinking about it, and that's probably getting rid of two thirds of it. Now I'm doing that out of what's called the precautionary principle. Not doing that because I'm telling you this stuff causes cancer and heart disease. I don't know.

Interesting.

But the cost of mitigating it is low relative to the cost of being wrong.

Yeah, yeah. What about plastic bottles?

I try to avoid them.

Yeah. I can taste it.

Now.

We have, we had a filtration system put in and, and now if I go to the gas station, I want some more. I, I can taste the plastic. I couldn't before because I was so used to it, but I definitely tasted that.

And again, let's say you're on a road trip and you're parched and you pull over at a gas station and your choice is to stay parched or drink the water out of the plastic bottle. Drink the water out of the plastic bottle. That's better than getting a kidney stone. Okay, Right. Like again, people have to remember the dose effect of this stuff. Like I get, I'm amazed at how people completely lose the forest for the trees sometime on this thing and they all of a sudden become so fixated on, I can't ever touch anything that touched plastic. And yet they forget to work out, like, remember the priority list. Right.

Okay.

Yeah.

What about household chemicals? Does that play a big role in cancer?

Probably not as much as health influencers want you to believe.

Okay, yeah. What about sugar? Does cancer feed off sugar?

That's a bit of a gross oversimplification. The truth of the matter is cancer feeds off glucose. Glucose is the simplest breakdown product of all carbohydrates, or virtually all carbohydrates. The evidence that sugar is uniquely carcinogenic is virtually non existent, despite again, what every anti sugar health influencer wants you to believe. The evidence is awful for that statement, but sugar almost undoubtedly drives people to overeat. And there are really compelling biochemical reasons for that and decent experimental reasons for that, especially in animals. That high sugar diets will drive overeating, and overeating certainly drives cancer, but sugar does not. Cancer does not have a unique ability to consume fructose, which is the actual part of sugar that makes it sweet. So if you eat A bowl of rice, that's all glucose. If you eat sugar, it's half glucose, half fructose. Well, the cancer does not have a unique ability to consume the fructose. It just consumes the glucose. So you could frankly argue that rice is more carcinogenic than sugar, except for the fact that, again, as I said, maybe sugar drives people to eat a little bit more.

Okay, But.

But sugar is. Pardon me, the. The bigger driver of cancer from a nutrition perspective is likely the growth signals that are very prevalent with obesity and type 2 diabetes. So it's undoubtedly much more the high levels of insulin than the high levels of glucose that are problematic when you're trying to prevent or minimize cancer risk.

Okay, let's move into dementia. That's another thing that scares the hell out of me. More and more, it seems like people are getting dementia, Alzheimer's. How do we prevent that? Can we prevent that?

Well, we can definitely prevent some of it. I don't know that it's entirely preventable, just like I don't think any disease is entirely preventable. The closest of the maiden diseases that I think is, I think, again, I think type 2 diabetes and extreme metabolic disease and heart disease are the most preventable. I think the other two are less so. But we know a bunch of things, right? We know that there are a number of behaviors that really, really reduce your risk of dementia. So you can invert that statement and say that doing a lot of those things helps you prevent dementia. Right? So what are those things? So exercise has the most potent effect on reducing the risk of dementia. I mean, it's profound, actually. So there are lots of reasons that that could be the case. It could be that when you exercise, your muscles make these hormones called myokines, and that myokines are pro. Basically pro neuron, right? They promote neuronal growth. Exercise produces other hormones and proteins. So something called brain natriuretic peptide, another protein called Clotho, is made. We have a spike in clotho by about 15% right after we exercise.

We know very clearly through experiments in everything from mice to monkeys that when you inject people with those proteins, they transiently have an improvement in cognition. And even when you give those things to people or to animals in the early stages of cognitive impairment, it reverses it. So there's a whole bunch of reasons that are profoundly beneficial. Of course, exercise also plays an amazing role in metabolic health and vascular health, which, again, are two of the biggest risk factors for dementia, metabolic health and vascular health. We look at other things that can get in the way of brain health is disrupted sleep. So person who doesn't sleep enough or a person who doesn't get a high enough quality of sleep. So again, anything that we can do to improve sleep duration, quality, staging, et cetera, it's going to be important. All the things that hurt the heart, hurt the brain. So apob, blood pressure, smoking. We talked about metabolic health. Those things are bad for the heart, they're bad for the brain. So reducing apob, keeping blood pressure normal, not smoking, being metabolically healthy, exercising are. I mean, that's the playbook. And again, people really want there to be some special nootropic agent out there that you can just take that is going to just make your brain perfect.

And it's like you're rearranging the deck chairs on the Titanic. The most important thing is not to hit the iceberg. Don't hit the iceberg. That's the most important step. And that. Those are the things that we just talked about.

Everything else is I have heard in red. And, you know, and like I said, I don't know. I don't really know what I'm reading, if it's factual or not, but there's a lot of talk about psychedelics and help him with adhd, help him with anxiety, help him with addiction. And I did it. I did an ibogaine treatment about three years ago, came off booze. It'll be three years this Valentine's Day. Does that help with. There's also been talk about that helping with dementia, Alzheimer's.

I'm not familiar with that. I am familiar with a lot of the. Both the stories and certainly some of the reports, case reports of the benefits of iboga and ibogaine on alcohol, on opioids even more potently, very difficult to ignore. In other words. I really think there's something going on there, actually. Just spoke with a patient who came back from a long retreat in. It was either Mexico or Costa Rica. I think it was in Mexico. He was there for a week. And, you know, it's interesting. Like I asked, I always ask people when they do this, what are you in search of? Like, what. What's the. What was the reason for it? Right. Out of curiosity. Of course not. I'm not judging the experience. And he, he kind of went in there without a very clear objective. He wasn't going to solve a problem. But he said, it's very interesting. He came out of it and he was like, yeah, I just don't have any appetite for alcohol.

That's what happened to me.

So you didn't go in there specifically for that reason?

No, I didn't. I mean, used to be very heavy drinker and then by the time, which I still was a heavy drinker, but I'd kind of like gotten away from hard alcohol. Vodka was kind of my poison and then kind of moved into wine. 7 I was probably drinking a bottle, maybe a little bit more a night. But I went there for more anxieties, ptsd, traumatic brain injury type stuff and the same thing. I walked. I wanted to be more in the moment with my family. And I just interviewed former colleague after former colleague over and over again. And all these guys were just having these profound benefits that came out of it. And then when I came out, that was one of the things it was. I kicked caffeine for about six months. I kicked marijuana for close to six months. I've kicked booze completely. I haven't had a drop of alcohol in almost three years. I was more in the moment. And then, and then, yeah, so that there was all that kind of stuff was kind of a byproduct that I wasn't expecting. Caffeine was gone for quite a while. I only, I drink tea now instead of coffee.

Sugar. Kick that for probably three or four months and, and then it's interesting, right?

This is an experience of 10 minutes long, right?

Oh, no, I wouldn't say it's 10 minutes. It's. It's. I think it's about 12 hour experience.

Oh, really? Okay.

Yeah, I think it's about, I think the effects, you're kind of in it for about 12 hours and then, and then came out of it. And then, yeah, all these good things happen. I did wind up, it's been what, probably about three months since I've had any marijuana, which really decreased my sugar intake. But.

And that alone should also help your anxiety.

I think it did.

I think a lot of people, marijuana is a very interesting drug where for a, for a, for a high number of people in the short term, they think it's giving them a reduction of anxiety, but it's actually compounding their anxiety. And I had a woman on my podcast who talked about this at length and she talked about the number of patients where if she can just get them to stop marijuana for a month, they're going to, it starts to break the cycle of their anxiety. And of course, there are lots of people who use marijuana quite regularly have zero issues with anxiety. So again, I think like most things in mental health, it's really complicated to understand susceptibility. Windows, like why is it that one person, when they use this drug, something negative happens, another person can use the same drug and actually something quite positive happens. What's the susceptibility of that? Like, you know, we're really in our infancy of understanding these things, to put it mildly.

So, so there is no, there is nothing thus far that states that psychedelics may help with dementia.

Certainly nothing directly. Now look, you could make some indirect cases. And by the way, I don't include MDMA as a psychedelic because it's technically not a psychedelic, it's an empathogen. So it doesn't distort, you know, your perception. But as I'm sure you're aware from interviews you've done, I mean, MDMA is probably the more promising of all of those agents when it comes to treating ptsd. And it would be hard to make a case that if you took an individual who's suffering from PTSD and you freed them from the grip of that through MDMA guided therapy, that you aren't not just reducing their risk of near term issues that are associated with ptsd, but also long term issues, including cognitive decline. So again, I think there could be indirect and adjacent benefits of this. I just think with each psychedelic, as with each drug, you have to know the operating window of the drug, right? So like take something that's really obvious and predictable, like Tylenol. So when was the last time you took Tylenol for a headache or something?

It's been a long time.

All right, so but you know how it works. Your kids get a fever, you give them Tylenol, right? Like it has a really predictable operating window. You're like going to give this to you, you're going to feel better. Can't give you too much or I'll hurt your liver. If I give you too little, you're not going to feel anything. But like this is the dose at which it works. Advil, took an Advil if you pulled a muscle or something. Like super, super predictable mdma. Pretty predictable drug, right? Like for most people, somewhere between about 75 milligrams and 125 milligrams is going to produce a remarkably consistent effect. Now you layer that in to the right setting, with the right therapist, with the right intention, you start to get amazing clinical results with people. Now when you start to look at psilocybin, lsd, oh, it starts to become a lot less predictable. You can give the exact same dose to two different people or to the same person in two different settings. Wildly different result now go one step further and start talking about ayahuasca. I mean, all bets are off. Right? Like it's not even one molecule.

Right. Does that in any way diminish that people have life changing effects on these things? No, but there's a real buyer beware on these things in my mind. And I do think that again, I don't follow the space nearly as much as I used to. So this is, you know, but, but like, if I think about kind of where my interests in this space were seven or eight years ago, I felt like there was maybe just a little too much indexing on these things or the panacea. Everybody needs a shaman. Everybody needs to be doing ayahuasca all the time. And my view now is that's that's just insanely irresponsible. And I think for every great story you hear about someone, one, how often is the change durable? And B, what does the graveyard look like of people who have been kind of ravaged by some of these things? I think ibogaine and iboga are really interesting. And actually, if I could make one wish of the fda, it's that I really wish that they would reclassify it to permit it to be studied for addiction. Because I don't know how we can live in the world today where we see more than 100,000 people in this country die from fentanyl overdoses a year.

And we aren't interested in trying to free people of that addiction. And by the way, some will say, well, but iboga is very dangerous and you can run into cardiac toxicity. And it's like, yes, all of that is true, but it can be done safely. And the toxicity that comes with it has to be weighed against the toxicity of an ongoing opioid addiction.

Have you personally done any of these therapies?

Yes, I have not done iboga, but I've done most of the others.

For what reason?

You know, usually trying to. Trying to solve a problem, trying to. Trying to address a demon. And I've had some incredible experiences that have changed my life forever. Have given me compassion in areas where I never thought I could have it.

Can you share that?

Yeah, yeah. I think one of the most powerful experiences I ever had was probably 2017, so. And it was. I didn't go into this experience knowing what was going to happen, but. But I had a remarkable vision of something in my childhood that was quite unremarkable, but it was. And I'm sure you've heard this from people who have used high doses of psilocybin but you sort of disassociate. So you are no longer experiencing this thing from your viewpoint as where you were. And I'm trying to think how old I was. I was probably 13. So I was no longer 13. I was me as an adult, but I had lifted up to the top of the room and I was now watching me as the child with. With my father. And I was watching something, an interaction that we had, but through a totally different lens, which was through his eyes. And I saw the world through his eyes and I gained a compassion for him that has endured to this day in a way that I'm so grateful for. And it was, you know, I mean, it was. I woke up. I remember waking up and thinking someone had spilled water on the floor and realized it was my tears.

Wow. And I couldn't understand how there was so much water on the floor after this many hours. I mean, it was such a profound experience. That said, on the opposite side of that, Sean, I've had experiences with some of these agents that have. I described them as Guantanamo Bay for my soul. Just horrible experiences.

Do you continue to do those therapies?

No, I honestly think. I think I have extracted the value that can be extracted from them and I'm grateful for it. But I do not believe that there's any more value to me to be extracted from those agents with the exception of mdma. I still think mdma, because of its very gentle, forgiving nature, offers a wonderful opportunity to kind of heal oneself a little bit. But I think I'll never say never, but I'm not at all eager to re. Engage with any of the others. What about you?

You know? Yes, I do. Every once in a while. I have very clear intentions when I do it and have done psilocybin, five meo, iboga.

And that's what I was confusing. Sorry, it's five meo, that's the 10 minute ride. Yes, sir.

But what I see, especially in the veteran community is I see people, friends of mine, that they go and they do ibogaine, then they do psilocybin, then they do ayahuasca, then they're doing mdma, then they're mixing it all together, then they're going and doing peyote and they start living in that space and it's like, man, look, what are you digging for here? You have to actually take whatever you learned in that and change the habit and carry on with your life here in the real world. Otherwise it's just.

Yeah. There's a book by this title that talks about the difference between altered states and altered traits. And the idea here is every time you do one of these drugs, it alters your state, obviously. But unless it's altering a trait that is, once the effect of the drug is gone, is it gonna change the person I am? Does it make me a better person? If it doesn't, That's a litmus test that you shouldn't be doing it. And so that is the standard I hold myself to on these things. I have no interest in just having my state altered. If it's not going to address a trait. I don't care, I don't need. I actually like the state I'm in. I don't need to run from this place unless transiently doing so is going to help me fix something.

That's a great way to put it. What's the fourth one? Metabolic.

Metabolic disease. So this is everything from insulin resistance, fatty liver disease, type 2 diabetes, and this is in many ways probably the one that's growing at the fastest rate. So in the year you and I, well, I guess I'm 10 years older than you, but roughly when you and I were born, you know, we're talking 1% of the US population had type 2 diabetes. It's 10% today. Wow. You know, obesity rates have doubled in that period of time. So something's broken, right? Something is broken. And if you have type 2 diabetes, your risk of all cause mortality is 40% higher. Your risk of getting any of these other diseases is up to 50, in some cases 100% higher. Not to mention the personal toll this takes. Right. That doesn't count. All the other stuff, the blindness, the impotence, the amputations of digits, all the other stuff that comes with this, the cost of the healthcare system. And we could rattle off everything about this. Right? So, so what is it that's going on? Because obviously there's an association between weight and metabolic health, but it's not an ironclad association. And we know that weight by itself, excess weight by itself is not the problem.

It really has to go back to kind of that thing we talked about before, which is some people can store a lot of excess energy in the form of fat without it becoming metabolically toxic, without it kind of going into those other parts of the body where, where it leads to these horrible compensations. And I do think that the majority of this problem stems from nutrition. I think exercise can alleviate much of it. And as people are becoming less and less active at just kind of baseline activity level, they're more Susceptible to bad nutrition. Sleep factors into this more than most people realize. So if you're sleep deprived, your susceptibility for everything goes way up, including you're gonna, I mean, I'm sure you know, I know this from back when I was in residency. So every third night you're not sleeping those. That next day, my eating pattern was worse. I was more, I had more cravings, I would eat more crap. And your cortisol levels are through the roof. I mean, there's just a whole bunch of bad things that happen when you're not sleeping. So something about our food system isn't working. I don't think it's, I think it's actually more the obvious stuff, honestly, I don't think it's, I don't, I don't believe it's red dye in the foods.

And I think that all that stuff is like, those are rounding errors, right. I think the real issue is we, we culturally eat too much in this country. Our we, we do have a lot of processed food and we eat a ton of it. And any American who has spent time abroad will recognize immediately the difference in food. Yes, the food quality is better elsewhere, but there's a totally different culture about how much you eat, when you eat, the size of portions. Everything is, you know, everything is geared and kind of rigged against us here. And I think that's probably the single biggest factor that's driving it. Coupled with like, again, to give you a little example, right? Like, you don't see places like Costco in Europe the way you would see it here, right? Because over there you're going to go grocery shopping twice a week and you're going to just, you know, the fridges are smaller over there, right. They're not supersizing everything. So as much as people want to point to seed oils and red dyes and you're eating too many animal products, you're eating not enough animal products or whatever. Like, like the data just don't support that.

The data suggest it really comes down to we just eat a lot more nutrient, you know, calorie dense foods in way higher quantities than other people do. Now, of course, they're catching up to us. So in fairness, the rest of the world is doing their best to catch up to the United States because we certainly export the best of our food ideas.

So you don't, you know, there's a lot of talk about seed oils these days.

Oh, I'm actually in the process of trying to engage and I have engaged two people on this debate. So I won't name them, but you can probably figure out who they are. But two people on either extreme of this debate, and I'm actually trying to bring them on my podcast for a moderated debate. Now, I think podcast debates usually suck, and the reason is people can make up whatever they want and you can't fact check them in real time. So I've never actually watched a debate on a podcast that I didn't think was an absolute garbage waste of time. So in going to these two guys, I said, look, I don't have any interest in adding to the volume of crap out there, so if we do this, we're going to do it by my rules. And my rules are as follows. The question of what is being debated will be very, very clearly articulated a priori. All the research that each of you will use to address the question will be pre submitted such that everybody can review it. So this is, this is how a court works. Okay? So you will submit all of your data to you.

You will submit all of your data to you. And both of you will submit it to me and my research team. When a person is speaking in the debate, if they are citing a study, they may only cite from what was pre submitted. There is none of the pulling out of one's ass that is rampant in the podcast space when it comes to debates. And everything you say will be fact checked. So beware if you're making something up. We will fact check you and we will insert fact check and correction every time you misspeak.

Wow, when's that coming out?

We haven't. I mean, we're still trying to get everybody to agree to this and it might not happen. You know, I mean, I've tried to do this for vaccine safety, I've tried to do it for seed oils, I would like to do it for sugar. There are lots of topics we want to do it for. But you know, when push comes to shove, it's hard to get people to commit to that kind of rigor.

Can I ask you who, who's apprehensive? Is it the anti seed oil guy or the.

I, I won't say for sake of who these folks are. But, but I will say that even getting to agree on the question has been difficult. Wow. Right?

Wow, that's interesting.

But it's, it's really easy to just kind of blame your favorite boogeyman. Yeah, but, but when push comes to shove, like what is the data? What is the data?

Let's move into exercise. So it sounds like exercise helps pretty much. All of these four pillars that are these four disease types. What kind of exercise are you doing? What should people be doing? I mean, do they need to dedicate three hours a day to this? Does it have to be super strenuous? I mean, what do you recommend?

I think it's easier to talk about it through the lens of what does the output need to be. I think too much of exercise is talked about the input. You need to do this many hours of this, you need to do this many hours of this. And that's obviously a very helpful, helpful way to talk about it because it's easier and it's actionable. But it's better to at least start with what's the objective. And the objective is if you at least just look at the top level of the data, you want to have muscle mass. That puts you at about the 75th percentile of the population or better. The two easiest ways to measure that is something called appendicular lean mass index and fat free mass index. These can both be derived from a DEXA scan. That's a body scan that very quickly measures how much fat, muscle and bone density you have. And so that's one of our first optimizations. We really would love to get everybody to be at or above the 75th percentile of muscle mass. Now that's not going to be possible for everybody. There are some people whose build is so slight.

I mean, we have patients that come in our practice who are literally at the third percentile for muscle mass. I don't expect those people to ever get to the 75th percentile, but I bet I can get them to the 40th or 50th percentile over a few years. Second thing is you want to hit certain metrics of strength and you know, so you, you should be able to carry some fraction, depending on how old you are, your body weight or some fraction of it for a certain period of time. Right. You should be able to do a wall sit for a certain period of time. And again, you can discount this. Over time, as a person ages, the standard goes down, right? So when you were coming out of buds, my guess is like you could, I mean, you were Superman, right? Wouldn't hold you to that standard today. But, but there's a Standard For a 40 year old, a 50 year old, a 60 year old, a male, a female, et cetera. And so if you rattle off what all these standards are, I would say that becomes a very important thing that we want to be able to hold ourselves to and we'll come Back to how you get there.

There's a measurement that is the. A very accurate way to determine what a person's maximal aerobic capacity is. It's called VO2 Max. It's typically measured either on a stationary bike or on a treadmill when someone's hooked up to a mask. That measures oxygen concentration and volume of air consumed. And you can calculate how much oxygen was consumed. When you know that, you can tell a person where they are relative to people their age and their sex. And we have a very high standard for what we think you want to be. You know, we might say, look, I want you to be at the 97th or 98th percentile for your age and sex with respect to VO2 max. And then there are other markers of baseline aerobic fitness, what's called zone two. And we would say, we. We have a standard for what we would want you to be able to do. How many watts we would expect you to be able to put out relative to your body weight for an hour under these conditions. And so we can rattle off a whole lot of these goals. And then we can come back to your question of how should one do that?

And I don't tend to prescribe, like, you got to do this many hours of exercise. What I then do is I say, how many hours a week can you exercise, Sean? You tell me what you're willing to do. Not for one week when you're being a hero. Like, tell me what is sustainable for you for the next year. And then if you came back and said, look, man, my kids are one and three. I got this podcast, I'm doing 20 interviews a week. I got this business thing, I got this business thing. I can't do more than six hours a week of training right now. I'd say, okay, we're gonna work with six hours per week, and we're gonna. We might not get you to those goals within a year, but we're going to put you on the right path. And this is how we're going to balance the portfolio. If you came back and said, I can only do three hours per week, I'm going to be like, oh, God, okay, we're probably not going to make that much progress, but unless you're starting from zero, if you're starting from zero, three weeks, three hours a week is pretty awesome.

But if you're a reasonably, you know, quasi fit person who's at about the 50th percentile, we're not going to make huge progress in three hours a week. But we're not going to take any steps backwards, and that's important. And if you come in and say, I'm going for broke, man, you got me for 12 hours a week, then it's a different. Then it's a totally different training program.

How often do you exercise?

I mean, almost every day. I didn't exercise today because I had to, you know, fly in, and then I'm gonna fly back tonight. But I did today's workout yesterday. So I, I mean, my, my, my schedule is set up to exercise pretty much every day, but at least twice a month, there's kind of a forced day off due to travel.

Okay, so how, how many hours a week.

Right now? Let me think. Maybe eight hours a week.

Eight hours a week?

Yeah.

What kind of exercising these days?

You know, it's mostly just cycling and resistance training. I'm going to resume swimming again in a couple months, so I think I'll probably increase to about 12 hours per week total training time by spring, summer, and I think just bring swimming back in permanently to my life. I haven't swum in a long time, and I kind of miss it. And I also think it's, you know, kind of going back to something you said earlier, like, how do I spend my time? Swimming will be a form of exercise where I'm killing two birds with one stone. Well, I'll get the exercise, but it's also a bit of a mental health check. Whereas when I'm on my bike, I'm usually like, I'm indoors. I'm listening to a podcast or an audiobook. I'm not really turning it off. I'm trying to learn. When I'm strength training, I've got music on, so I'm kind of focused on what I'm doing there. But swimming is, as you know, you've probably spent a ton of time in the water. You only hear the water. You hear yourself breathing, and you hear the sound of the water. So that's why I'm kind of excited to get back into swimming.

And that'll probably take me up to 12 hours a week.

Let's talk about emotional health. This is something you talk about about kind of broached psychedelics. What, what other kind of things should people be doing for emotional health?

No, I mean, I think just asking themselves questions, you know, like trying to. Trying to understand the root of. Of. Of what's going on. Like what. You know, how can I name my emotions? Right. Why do I feel away? Why do I feel the way I feel? Who am I? Who do I feel Connected to, Who do I not feel connected to? So I think just being kind of curious is a very important step. I think this is an area that comes a lot easier to women than to men. I think men, particularly young men, just don't necessarily possess the vocabulary sometimes to even think through some of this stuff. And I think you can, you just, you get into trouble for it, right? You, you, you end up going, going down a road where you can, you know, you, you, you can poison relationships because you didn't know better, right? Because you didn't, you didn't, you didn't know how to act. You, you, maybe you didn't have a role model in that way. And, and I think there's different, there's different ways to do it. I mean, you can, and I think in my case the issue was workaholism, perfectionism, anger, being great tools that were highly valuable when I was young that start to become maladaptive when you get older and then you have kids and then you realize what served me well when I was a 16 year old is not going to serve me well when I'm a 46 year old.

It's sleep. How do we improve our sleep? Do you recommend everybody do a sleep study?

No, I don't think so. Look, a lot of people, if you spend two minutes with them, asking them questions, you can figure out they don't have an issue with their sleep. Their sleep is great. There are a couple of really great surveys you can take online. There's one called the PSQR which is probably the most important one anyone should take. So if you just Google PSQR and go and take this survey, it asks you a bunch of questions and it'll pretty quickly tell you if you have a sleep issue. And if you do, then, you know, you kind of want to get into the, well, what's going on and just start doing some accounting like what time do I go to bed? Am I consistent in my bedtime? Am I consistent in my wake up time? How many hours am I getting in bed? Because if you're not even spending seven and a half to eight hours in bed, yeah, you're probably going to be shortchanged in sleep because it's hard to sleep more than 90% of the time you're in bed. So you know, I try to be in bed for eight to eight and a half hours to get seven and a half to eight hours of sleep.

And of course nowadays, you know, tracking devices are ubiquitous so you can measure with reasonable accuracy like how you're Sleeping, what staging you're getting and things like that. And then there's just a whole bunch of really, really straightforward sleep hygiene things that everybody, I think, should be doing, and everybody knows what they are. I could rattle them off, but I don't think anybody would be surprised by them. It's just a behavioral challenge, right? Like, I don't think there's anybody who's going to listen to us, who's going to think, wait, I shouldn't be looking at my phone before bed. Right? So everybody knows that. But sometimes it's just hard to make the discipline of not looking at your phone for, let's say, an hour to two hours before bed, having a bedtime routine, keeping the room really dark, really cold, not having, you know, electronics in the room, not eating before bed for maybe three hours, not having alcohol before bed. All these things make such a big difference. And then when you stack them all together, it's like you're gonna sleep well. And then of course, there's always a subset of people where after doing all of that stuff, sleep is still problematic.

And then a sleep test can be really helpful. You know, you do learn that, hey, a person might have sleep apnea and even if they lose weight, it doesn't fix, or maybe their normal weight because there are still people who get sleep apnea that are of totally normal weight, even though it's a condition that disproportionately afflicts people who are overweight. And then, yeah, you might, you know, you give that person a CPAP machine and it changes their life.

Man, there's a lot of, it's a lot of great information. Thank you. Is there anything that we didn't cover that you'd like to cover?

No, I don't think so.

Then we'll end with this. Just want to know what is, you know, what is your daily routine? Not when you're on travel and going to podcasts. What is, what is your picture perfect daily routine that you, that you, you don't like to interrupt?

You know, I like to get up early, make coffee in an ideal world, have 15 minutes with my wife where we're sitting in the dark, having coffee, catching up, kids are up, then getting the kids ready for school. So making breakfast and a really good day, get a chess game in with, with one of the boys before school, get the kids off to school. By now it's about 7:15. I will typically head right into my office at that point and do my first scan of email and then just address anything that needs to be addressed. And then actually at that moment in time is when I can turn my attention to whatever my most important task of the day is from a creative perspective. So that's when I can do my best writing, editing, thinking. I've done my prep for the day before, the night before or for that day so I know which patients I'm talking to. I've already gone through all that stuff. And then I'll typically go and exercise.

So what time?

It depends, but probably now it's like 8:30, so I'll, I'll work out and I don't. So I don't schedule anything until 10 or 11 in the morning. So I just have a hard rule unless I have a call in Europe, then I'll typically do that at 7:15 the second the boys and my daughter leave. So. But assuming I don't have a European call, it's going to be 10 or 11 is first scheduled meeting. And so if it's 10, I need to be in the gym by 8. If it's 11, I'll go 8:30. And then I like to try to get a quick sauna in for 20 minutes and then get ready for work. And then, so work from 11 to 5, 5:30. And then, you know, help with dinner, goof off a little bit after dinner again, play some chess, just, you know, kind of hang out with the kids. It again, depends on the season. Right. So in the summer you get a little more leeway. We go outside, we'll play baseball or you know, do something in the winter, you know, or during school, you know, it's maybe more directed towards kind of the night routine.

Once the kids are down, I'll typically work again for another one to two hours and then kind of like to spend the last hour before bed off work, just, you know, vegging, hanging out with my wife, watch Netflix, maybe do a sauna if we, if I didn't do one earlier in the day.

Right on.

Pretty boring life, man.

Hey, that sounds pretty. That sounds pretty good to me. But Peter, I just want to say thank you for your time. Thank you for coming. I learned a ton from you and I hope to see you again.

Well, thanks for having me, Sean.

Best of luck.

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