Longevity begins with a simple distinction. Lifespan asks how long we live. Healthspan asks how well those years are lived. The work is not to chase age for its own sake, but to protect the strength, clarity, and independence that make time feel usable.
This transcript is provided for reference, with timestamp links back to the original conversation.
You could make a case that most of the benefits in um lifespan uh roughly I would say three quarters of the benefits you can get towards a longer life come solely from pursuing better health. I want to say that again because I think it is I I for me at least it's such a profound statement. If you never thought once about trying to live a longer life and focused relentlessly on how can I improve my strength, my endurance, my stamina, my you know, and again all the nuance around these things, my balance, my coordination, my processing speed, uh my working memory, my emotional health, my happiness, my relationships with If you only focused on those things and never once thought about heart disease, cancer, Alzheimer's disease specifically, I still believe you would capture three quarters of the way towards optimizing your lifespan. Hey everyone, welcome to the Drive podcast. I'm your host Peter Attia. Peter, welcome to a special episode. How you doing? Great. Awesome. Well, for today's episode we're going to do something a little different. Um one thing we know and we can hear from people is if you look at podcast, sometimes podcasts aren't the best way to learn about information and part of that is because each week we cover a different topic in different detail and it maybe cancer one week, exercise the next week, Alzheimer's, whatever it may be and we go into different levels of detail. And so we also know we have newer people who are listening and sometimes they can be a little overwhelmed by all the different things and so what we wanted to do was record an episode which is basically longevity 101. And so we're just going to go through core lifespan, healthspan, each
through core lifespan, healthspan, each of the tactics and just touch on the core frameworks to give people kind of a foundation of how they can think about their own longevity and also how they can think about when they listen to the podcast how these different pieces fit together. And so if you've listened since episode one you might not need to listen to this one, but it might be one you share with someone to be like, "Hey, this is what this guy talks about." So we're going to hit all the five tactics, some real basic questions, but it should be pretty simple, pretty high-level. So with that said, anything you want to add before we get into it? I mean, simple and high-level aren't typically words I associate with very well. So I'm a little uh I'm a little gun-shy about how we do this, but let's let's give it a shot. So you're saying the first question that I should ask is what did you eat today for lunch and why should everyone eat that for lunch every day as well? Absolutely. That would be a great question. Perfect. Well, I've I think I've already forgotten what I No, I remember what I had. All right. We'll save that for the nutrition section, but um starting off with just a few foundational level questions. The first being how do you even define this word longevity? It's a word that get thrown around a lot, means different things to different people. I think it'd be nice just to be like for this conversation to anchor what we're talking about, how do you define longevity? Yeah. I I don't um I don't make an argument that my definition is the best definition, uh but I agree with the idea that whenever someone is talking about it, um it's worth asking them what they mean by it. And it's also why I tend to bristle at the um the association with longevity because you know, if someone says, "Oh, do Do you you know, are you a longevity doctor or something like that?" I have no idea if they know what longevity means
if they know what longevity means according to my definition, which again is not to say it's the right definition, but it's the lens through which I think about it and therefore everything I talk about, any question I answer will be through the lens. So um So the way I think about it and I suspect the way some others do as well is that uh longevity is well, it's a function. Uh I think so again, I tend to think of things mathematically made up of two vectors. And one of these vectors is lifespan and one of these vectors is healthspan. And both of these vectors are necessary to, you know, demonstrate the function of longevity. Now, one of these vectors is much easier to understand because it is um it is discrete, it is binary, um and it is objective. And that is the lifespan vector. So there are some edge cases, but for the most part you are alive or you are dead. And we think of that through the lens of death certificate death. Um again, we could talk about an edge case. You can have an individual who is brain dead, but who is being kept alive um and and we could debate whether that person is dead or alive. But I think for most people there's very little confusion about what it means to be alive or dead. And notice that lifespan says nothing about the quality of a person's life. We'll save that for a second. Um but in a nutshell, that is lifespan. It is to be respiring or not to be respiring. Um and it is again one of the vectors of of longevity. So um in as much as we want to increase longevity we presumably want to have something to do with increasing lifespan. The second vector that makes up this longevity function is the healthspan vector. This is far more complicated to
vector. This is far more complicated to explain. Um it is far more subjective. Uh it is analog as opposed to digital, meaning it is not sort of discrete on-off. It is, you know, variable. And um it also has three components in the way that I think about it. So one of those is a physical component. One of them is a cognitive component. And one of those is an emotional component. Now in the first version of Outlive when I wrote it or maybe it was the second version, but not the version that got published, I I went to great lengths to describe that the cardiorespiratory death, the the sort of, you know, I'm not respiring death certificate death as type one death. And then I went into great machinations to talk about the three types of decline in healthspan as physical, cognitive, and emotional death. And I think for probably good reason, everybody uh the publisher and and Bill, everybody really pushed back on that and they thought it was a little too morbid to talk about physical death as, you know, the death of your exoskeleton and cognitive decline. And I think they were right. I think that death was probably too strong a word there, but my point was that um all of those things can be robbed of a person and even though they're still technically alive, their quality of life has been sapped. So let's not think of it that way. Let's think of it as you have these three sub-vectors of the vector healthspan and um each of those has, you know, there are ways that we can try to quantify them. Um and um but ultimately I think people will have their own subjective assessment of what it means to be physically healthy or what it means to be cognitively healthy or what it means to be emotionally
or what it means to be emotionally healthy. Um I think another thing that's worth pointing out here is that two of those three inevitably decline with age. So the physical component of healthspan, which I'll define in some detail in a moment, and the cognitive component of healthspan they they very predictably decline with age. Now, that doesn't mean that everybody's decline at the same rate and that doesn't mean that for everybody the decline reaches a level that is quote unquote pathological. But it simply means, and I was thinking about this today in the gym actually. I was like, "Wow, it is really so obvious to me with each passing day that I am completely past my prime physically and cognitively." I mean, I am and I and I've also accepted the fact that like I will never again be as physically strong, fit, flexible, free of pain, like pick your metrics that all make up physical healthspan. I will never again reach the pinnacles that I had reached in my late teens and 20s. And similarly, you know, cognitively um you know, I'm I'm basically a compared to the person I used to be uh in terms of processing speed, problem-solving, just raw intellectual horsepower. Um and and on you know, those things are going to decline even further. Um Now, there is more nuance to this um because there are certain things physically today that I think I actually do better than I did before. In other words, I've you know, you take advantage of the fact that as you're getting you know, less explosive, less powerful, well, you can still kind of maintain strength um and if you learn to move more intelligently, you can actually become more effective. And similarly, as our intelligence transitions from a more fluid form when we're young to a more crystallized experiential form when
crystallized experiential form when we're older, um we we you know, we still have remarkable ability to contribute. But there's no denying that on some of the prime levers against which you would evaluate these, we're in a state of decline. Conversely, the third part of uh health span, which is emotional health, it actually doesn't really tie to age much at all. Uh depending on how you evaluate it, it almost seems to have a U-shaped curve. Um not a you know, really big obvious U, but kind of a dip in I think statistically probably the late 40s, um and then a gradual rising again. So, one of the things that I always try to remind myself and then remind my patients is this is something we can really look forward to provided we do the work, right? Is that, you know, I can be emotionally better off in a decade than I am today, and I am certainly better off today than I was a decade ago. So, um I would say that that is at the highest level how I describe longevity, and therefore, when a patient comes to me and says, um you know, I'm interested in longevity, I want to make sure that what they're interested in is what I understand because there are many other definitions of longevity out there, and if your definition of longevity is I want to live to be 200, um I I wouldn't obviously be able to help you. Um so, the way I think about it is longevity means how do we live longer? And I I think that means, you know, years longer, a decade longer. It doesn't mean a doubling of lifespan. And how do we prevent the um sort of Well, I think a better way to describe it is how do we reduce the rate of decline of health span? That That would probably be uh kind of the most operative way to talk about it. So, that's
So, that's obviously very verbose, and that's why I think it's not something that, you know, you explain very quickly to somebody. Um but given that that's the purpose of what we're talking about today, I think it's it's probably worth going into that detail. And to double click on that cuz you kind of at the end there mentioned where I feel like a lot of times when longevity and that word gets thrown around, it is on the how long you live side. Um so, I think it's worth double clicking. Why do you think it's so important for someone to not only care about how long they live, the lifespan side, but also the health span side that you said there, and also how well they live? There are several reasons for this to be relevant. Um you know, first you can think of this kind of at the level of just a a thought experiment, right? So, in the book, I write about the Greek god Tithonus, and how he wished for immortality. Um he was of course granted his wish, but because he had forgot to ask for uh eternal youth, he became, you know, this uh you know, in indefinitely suffering human being who continued to age in perpetuity while his body declined. So, I I think just sort of theoretically, I think anybody who thinks about it for long enough would realize that any desire to live longer has to be accompanied by a desire to preserve health span. So, I believe that anybody who thinks they want to live to be 200, implicit within that, I hope, is the desire to function as someone who is much younger, right? If I if a person says to me, I want to live to be 95, well, I'm assuming, and if not, we'll tease this out, I'm assuming they don't want to look like most 95-year - olds, right? What I assume is I want to live to be 95, but I would hope that in the
to be 95, but I would hope that in the final years of my life, I function like a 75-year - old. Right? A healthy 75-year - old. So that's why. I think the second thing here is and the reason at least for me that health span is such an important focus, and we're going to talk, I'm sure, about medicine 2. 0 versus medicine 3. 0, but one of the most important concepts within medicine 3. 0 is an equal obsession with health span as lifespan. And again, health span by itself is valuable at any given age, whether it's 40, 50, 70, or 80, to for your age have better physical uh a better physical body, a better cognitive mind, better emotional health always exceeds being below it. It's so self-evident, it doesn't require stating it. Secondly, all the things that you do to improve your health span are twofers. And anybody who works for me knows what a twofer is and a threefer and a fourfer and how much I hate onefers. So, a twofer means you're getting a two for the price of one. So, when you do all those things to improve your health span, you are also improving your lifespan. You could make a case that most of the benefits in um lifespan, uh roughly I would say three quarters of the benefits you can get towards a longer life come solely from pursuing better health. I want to say that again because I think it is I I for me at least it's such a profound statement. If you never thought once about trying to live a longer life and focused relentlessly on how can I improve my strength, my endurance, my
improve my strength, my endurance, my stamina, my, you know, and again, all the nuance around these things, my balance, my coordination, my processing speed, uh my working memory, my emotional health, my happiness, my relationships, if you only focused on those things and never once thought about heart disease, cancer, Alzheimer's disease specifically, I still believe you would capture three quarters of the way towards optimizing your lifespan. Again, it I think it's a bold statement. I can't confirm that that's exactly correct, right? I mean, that's not a studyable question, but my conviction is quite strong that health span pursuit of health span is valuable in its own right even if it didn't lengthen life at all, and the fact is it probably does, and it probably does to a greater effect than all of the efforts that largely medicine 2. 0 puts directly into lifespan extension. And you hinted at it there, and so I think it's worth just kind of going into it. You've written about it, too, but do you want to talk real quick about medicine 1. 0, 2. 0, 3. 0? So, medicine 1. 0 is the type of medicine that dominated for virtually all of human existence. So, if we, you know, if we argue that humans have been around, you know, Homo sapiens have been around about 250, 000 years, from from the arrival of our species until the latter part of the 19th century, um we were practicing this thing called medicine 1. 0, which truthfully wasn't medicine in the way that we think about it today. It wasn't scientific in the way that we understand science today. It was the best that humans could do missing this tool, right? Missing this tool of inference. And you know, it relied on a belief about, you know, perhaps gods, spirits, humors, um
perhaps gods, spirits, humors, um and so, you know, it to be just blunt was largely ineffective. Um and so, you know, the the doctor of the past didn't have any tools in large part because they didn't have any understanding of what was going on in terms of disease processes. So, not surprisingly, humans uh didn't live that long on average, uh and you know, the median life expectancy would have been into the late 30s or early 40s. Um the causes of death were typically related to communicable diseases, uh infections, and death associated um with child mortality and um maternal mortality. So, just the process of having a baby was incredibly dangerous to both the mother and the baby. Um and obviously, that heavily skews lifespan data. If you're killing young mothers and babies in the process of having babies, you're really bringing down lifespan and life expectancy. And couple that with infections, communicable diseases, and trauma, um and you know, I think most people aren't surprised to know that yep, that's pretty much how people died. Um and then of course, after the after, you know, the Civil War and we we move into the latter part of the 19th century, a couple of things start to come together. Now, the first of these actually happened in the 17th century, um but it wouldn't become germane to medicine until 300 years later, um or 200 years later, rather. And that was Francis Bacon codifying the scientific method. So, again, this is something, you know, we take for granted today, but this idea that you would make an observation, which is what science is all about. You observe something around you. You observe something in the natural world. You form a hypothesis about why it is happening. You design an experiment that is equipped to test the hypothesis.
equipped to test the hypothesis. You conduct the experiment and measure the outcome and you compare the results of the experiment to the prediction of the hypothesis. And that is effectively the framework for what science is. And so with that as the scaffolding upon which people could begin to make inference, you now layer on some other remarkable discoveries and insights. So, a creation of the light microscope, the advent of germ theory and ultimately the development of antimicrobial agents. All of these things collectively, I think I would add to that just the practice of sanitation, led to a remarkable change in the trajectory of human lifespan. Um and of course it's so remarkable that if you go from the late 1800s until, you know, fast forward just 100 years, which again is a sliver of time across a 250, 000 year timeline, human lifespan approximately doubled. Um so, you know, again, three, four, five generations to double human lifespan that had previously been unchanged for hundreds of generations is a remarkable feat. And we call this new system of medicine medicine 2. 0. Now, there's lots of more nuance to get into medicine 2. 0. Uh medicine 2. 0 ultimately developed even more remarkable statistical tools that allowed for things called randomized controlled experiments or RCTs, randomized controlled trials. And this really allowed medicine 2. 0 to flourish and become supercharged. And um obviously for the most part medicine 1. 0 was completely displaced by this. Now, that doesn't mean that there aren't still some quacks out there that practice witchcraft, but for the most part, um you know, when a person has an
part, um you know, when a person has an infection, when a person has congestive heart failure, when a person is in renal failure, when a person has appendicitis and needs to have their appendix removed, when a woman has a complicated pregnancy, all of these things now for people who are in the developed world are really easy things to manage using the toolkit of medicine 2. 0. So, again, medicine 2. 0 was and remains an enormous success and I certainly wouldn't be sitting here talking without medicine 2. 0. I would likely have been dead already as would you have. So, why do we need to go any further? Why do we need a medicine 3. 0? Well, for all of the successes of medicine 2. 0, it has indeed had a couple of obvious and notable failures. Um the most obvious is that lifespan has largely faltered. So, there really has not been any extension of lifespan beyond that which came from the eradication of the conditions that led to the demise of most people uh between the Civil War and the end of the First World War. Um in particular, the types of diseases that kill people today uh are very different types of diseases from those that killed people 150 years ago. So, the leading causes of death, which I describe as the four horsemen of death, uh are the diseases of atherosclerosis. So, uh coronary artery disease and cerebrovascular disease, cancer, the neurodegenerative diseases and dementing diseases. Uh so, Alzheimer's disease, Parkinson's disease, Lewy body dementia, vascular dementia, frontotemporal dementia, all of those diseases. And then the slew of metabolic diseases that while directly not responsible for an enormous number of lives lost compared to the other categories,
compared to the other categories, uh indirectly contribute immensely by amplifying all of these. Now, there's couple of other things I haven't mentioned there at the population level. Chronic obstructive pulmonary disease is also an enormous cause of death. Um but its cause is almost exclusively related to cigarette smoking. So, I don't really hold medicine 2. 0 particularly responsible for the failure of mitigating that. That's really more of a public health question. Um if people don't smoke, they don't get COPD even though COPD is one of the leading causes of death. Um there are of course accidental deaths um and we can spend some time talking about those later because there's an enormous spread of what those look like across lifespan and of course by geography. So, in essence, the purpose of medicine 3. 0 is to try to address where medicine 2. 0 has fallen short. It's not to replace medicine 2. 0. Um I certainly from time to time um hear feedback from people who I think misunderstand the And uh there there's nowhere that I'm suggesting that we need to do away with medicine 2. 0, that we don't want the system as it exists today in its capacity to do what it can do. What I argue is that we need to shift resources away from solely focusing on medicine 2. 0 to focusing on what we'll talk about in a minute, which is medicine 3. 0. So, if we're putting 100 units of resources today into medicine 2. 0, I think most economists would argue that's still too many units of of economic input. In other words, healthcare makes up far too big a section of the economy. So, maybe instead of it being 100 units that go into healthcare, it really ought to be closer to 60 units that go into healthcare. And I would argue further, maybe 30 of
And I would argue further, maybe 30 of those units should be aimed towards medicine 3. 0 and 30 of those units should be aimed towards medicine 2. 0 because when it hits the fan and something goes really wrong, you know, again, trauma, infection, heart attack, by all means you want medicine 2. 0 there to backstop those things. But medicine 3. 0's job is to make those encounters with medicine 2. 0 less frequent, less severe and later in life. So, that is effectively the difference. The the final point I'll make on that is kind of just briefly explaining what medicine 3. 0 is, which is because at this point it's self-evident, it almost doesn't need to be explained. Medicine 3. 0 really has two main hallmarks. Uh the first is that it is aimed at preventing rather than treating chronic disease by acting early, acting aggressively and tailoring the therapies to the individuals based on the best available evidence, which is not necessarily going to be derivable from randomized controlled trials. And the second pillar of medicine 3. 0 is that healthspan is to be given at least as much effort and attention as lifespan. This is again another enormous difference between medicine 2. 0 and medicine 3. 0. Medicine 2. 0 does not place emphasis on healthspan. Its emphasis on healthspan is anywhere from zero to very small depending on the subspecialty. So, there are certainly some physicians whose practices do take them a little bit into the arena of healthspan. But um you know, outside of for example, physicians uh or healthcare providers who work specifically in the arena of mental health, again, it's relatively low. Obviously, orthopedic surgery is a
Obviously, orthopedic surgery is a pri - is a you know, a discipline of medicine that is more squarely uh featured in the healthspan arena. But for the most part, most of the healthcare dollars are spent on addressing uh and trying to elongate lifespan uh and I would argue that we need to be, you know, putting just as much effort into healthspan. So, that's that's the fundamental difference between medicine 3. 0, 2. 0 and 1. 0. And to double click on the four horsemen just a little bit, you mentioned what those four are. But do you also want to talk a little bit about for each of them what we know in terms of prevention, right? So, if medicine 3. 0 prevention's really important, you know, how do you think about our knowledge of those diseases as it relates to someone who is trying to live as long as possible? Sure. So, we'll take them from the top. So, the atherosclerotic diseases um along with the fourth horseman, which is the metabolic diseases, are probably the two that we have the most insight into um as far as what are the pathophysiologic drivers. And therefore, we either theoretically uh or in some cases practically also have, I think, the best insight into how to prevent them. So, ASCVD is a disease that has both a genetic component and an environmental component. But it really doesn't have much of a component of luck as far as we can tell. So, you know, stochastic processes involving mutations uh doesn't seem to play a role, right? There's there's just pure causality from the standpoint of environmental triggers and from genetic inheritance. So, both of those factors play through three pathways, all of which are important. So, first is a lipoprotein pathway, second is an endothelial pathway, and third is an inflammatory pathway.
third is an inflammatory pathway. But, I realize as I'm saying that, it doesn't make a lot of sense. So, I'm going to try to step back and put this into English. The three things that have to happen for atherosclerotic disease are as follows. The first is a molecule called a lipoprotein, which carries cholesterol through the body. And specifically, a lipoprotein that has an apoB protein on it, cuz there are lipoproteins that don't have apoBs on them, and we don't have to worry about those. But, the lipoprotein that have apoBs on them can enter the artery wall when the endothelium is intact, but they do so more prevalently and more easily when the endothelium is damaged. The endothelium is simply the lining of cells on the innermost membrane, I mean, closest to the artery or outermost from the standpoint of the artery wall, the one that is most in contact with the circulation. If those apoB wrapped lipoprotein get trapped inside the endothelial layer, a chemical process known as oxidation takes place, and that leads to inflammation. What that means is the body thinks something is wrong and I need to fight it. Just as when you get an infection, a healthy immune system detects the inflammation caused by the microbial agent, and it sends the troops there to get rid of it. But, in this case, the insult does not come from an infection, it comes from the oxidation of the cholesterol contained within the apoB particle as it sits in the endothelium. And that process initiates a devastating cascade of events that ultimately can create so much damage in the wall of the artery that it can lead to a rupture of
artery that it can lead to a rupture of the plaque, which is the repairing process. The rupture of that plaque acutely leads to blood loss and ultimately oxygen loss to the muscles of the heart beyond the point of that blockage. That process is known as a heart attack, and about 50% of the time, it is fatal the first time a person has one. So, if you want to think about preventing cardiovascular disease, ischemic cardiovascular disease, you have to have an insight into all of those things. You have to be thinking about, how do I have fewer apoB particles? Because the more of those particles you have, the more of them that are going to enter the endothelial space. The data on this is as unambiguous as any data are in medicine from clinical trials, epidemiologic trials, and Mendelian randomization. In other words, you have the only three layers of evidence you can ever look to, experimental data, MR, and clinical epi, and they all say the same thing. There is a log-linear reduction in ASCVD as apoB goes down. The second thing you have to do is you have to protect your endothelium. So, anything that aggravates and weakens and makes the endothelium more vulnerable to penetration by apoB is problematic. And the most common factors that we think are doing that are smoking, blood pressure, and very likely the metabolic conditions that cluster with insulin resistance, hyperinsulinemia, and type 2 diabetes. So, some combination of elevated glucose, elevated insulin, and other metabolic
elevated insulin, and other metabolic byproducts such as homocysteine, uric acid, all of these things serve to weaken the endothelium along with elevated blood pressure and smoking, and that creates a greater susceptibility. Again, it's not surprising that all of those things pose about an equal risk to cardiovascular disease as does the presence of elevated apoB. And then, the third piece of the puzzle, and the one for which we really don't do much directly in the way of treatment, is the higher the inflammation, the more likely the higher this is going to be. And the reason this is probably lesser of the three is, with very rare exceptions, is it a direct therapeutic tool. In other words, we clearly therapeutically address the first two, right? We therapeutically lower apoB, we manage blood pressure, we tell people to not smoking, you know, tell people to not smoke, which of course is a therapy. We, you know, use exercise and nutrition to manage metabolic health and even pharmacology. But, directly from a pharmacologic standpoint, we don't really manage inflammation. We can, there are a couple of agents that are used somewhat not impressively, and maybe somewhat on the margins impressively. But, most of the evidence around reducing inflammation probably comes from doing things much more broadly around nutrition, sleep, and exercise that we've talked about elsewhere. So, in a nutshell, that's really what it comes down to, and it's for that reason that I'm often making a very bold statement, which is, even though cardiovascular disease is the leading cause of death in men, in women, in the United States, but also in the world, it doesn't need to be. It really, really doesn't need to be. And it is a very bizarre tragedy that, you know, 19 million people a year still die from cardiovascular disease given how much we know about what causes
given how much we know about what causes it and how many tools we have to prevent it. So, that's the first You kind of mentioned the first, second horseman there. How do you think about prevention for the others, which is neurodegenerative diseases and cancers? Yeah, so let's take them in order. So, cancer would be the next most deadly of the horsemen. And here is one where a lot of what I said with respect to heart diseases is actually quite different. You know, in heart disease, we we really have a pretty clear sense of what the genetics look like. So, there are a handful of genetic things like familial hypercholesterolemia, which is a very, very heterogeneous condition that raises apolipoprotein B, LP little A, which we'll save for another time. We've got lots of content on that. But, when it comes to cancer, we we know that, boy, there are some really clear and obvious genetic drivers of cancer. Like, there are a handful of genes, some that many people have heard of, such as BRCA1 or BRCA2, which are heavily associated with breast cancer, or Lynch syndrome, which would be heavily associated with colon cancer and other types of cancer. But, for the most part, when we say that cancer runs in a person's family, we still aren't really even able to identify the genes through which this is transmitted. It appears to be very polygenic. Furthermore, while we know of at least two significant environmental triggers for cancer, smoking and obesity, and I'll say more about obesity in a second, um we actually have very little to say about many other triggers. Despite what people would have you believe, we have very little insight about if at
we have very little insight about if at all foods, you know, specific foods at isocaloric amounts. So, we can talk about an abundance of food, cuz that factors into the obesity trigger. But, if we're talking about a bunch of people eating an isocaloric energy balanced diet, again, despite all of the propaganda around this, oh, red meat this or soy that or whatever, there's actually just the scantest of evidence to suggest that any of these are promoting cancer in the slightest way. So, um when you take all of this together, what you realize is that, okay, smoking is clearly driving cancer, obesity is clearly driving cancer, not all cancers, but many cancers, about two-thirds of cancers have a very strong tie to obesity. I think if you look under the hood of that, you'll realize it's probably not the excess fat per se or the adiposity that's driving cancer, and rather it's the growth factors that are doing it. So, obesity comes with more inflammation, comes with more growth factors such as insulin and IGF, and it seems more likely that those are the things that are actually leading the increase in cancer. But, that leaves a bit of a vacancy in terms of what else explains it. And this is where, you know, a scientist like Bert Vogelstein and others would suggest that look, there's actually just a component of really bad luck here. Um, you know, there are mutations that occur. Every cancer begins with a mutation, and most of those are somatic mutations. That means that most of those are mutations that occur in cells that were developed normally, right? So, these are your your germline, the cells you inherited. These were normal cells, but then mutations were acquired. And mutations fall into one of two categories. These are either mutations
categories. These are either mutations that are tumor-promoting, so oncogenic mutations, or they are mutations of tumor suppression. So, we have genes that are set out to suppress cancer, and if you get a mutation in one of those, the body loses the ability to suppress cancer. And then we get mutations in genes that turn cancer on. And again, a number of these are inherited, but many of them most of them are acquired. And the what is vexing us still. And again, I think the best working hypothesis is that um a bad luck plays a lot of role in that. Now, you know, it would be a topic for an entirely different podcast to look at other things that may be triggering those mutations. Again, in some cases we know that viruses play a role in those mutations. But where what I'm really talking about is where do the majority of these come from? And and anyway, that that's an area of of huge interest. And um the other problem with cancer that also is not afforded to cardiovascular disease is the treatment options are fewer. Um or I shouldn't say are fewer, I would say are less effective. So, um a person today who has advanced cardiovascular disease has a much better prognosis I I much better prognosis than a person today who has very advanced cancer. Uh a person today with stage four, uh i. e. metastatic, uh endothelial tumors, so that means a solid organ tumor like breast, lung, pancreas, prostate, colon, one of the sort of quote-unquote bread and butter tumors, a person today who has one of those cancers that has spread from its original site to a distant site, that's metastatic or stage four cancer, that person has about the same 10-year survival as a person did with
10-year survival as a person did with that tumor 50 years ago. They have a much longer median survival. They will live longer. They might live for 5 years instead of 1 year, and that's nothing to sneeze at. Um but they're not cured at any higher a rate. Um and and obviously that's a discouraging statistic. Um so, that's um you know, as we think about cancer, we we obviously think the first and most important thing is to do everything you can to avoid getting it. But as I alluded to, that playbook is not as thick as the don't get heart disease playbook. Um and that leads to a very controversial thing that I talk about, which is the importance of early and aggressive screening. Um and again, we don't have to go into that now. We've already devoted tons of content to the arguments for and against that approach, but hopefully this explains why um that is still a position I hold. And so, looking at the last of the horsemen, neurodegenerative disease such as Alzheimer's, um something we get asked a lot about a lot, how does that look in terms of what you kind of discussed on cancer, cardiovascular disease as it relates to prevention? Well, I would say it's a little bit in the middle. Um in other words, I think we actually have a slightly better sense of some of the causes. Uh not not in all cases, um but certainly with Alzheimer's disease, we're getting a much better sense of which people are susceptible, what genes play a role from a genetic susceptibility standpoint. And genes do play a pretty big role there. Uh and we also understand the other factors. And part of the reason for this, Nick, is there's a very simple but surprisingly accurate adage, which states, "What's good for the heart is good for the brain."
good for the brain." And study after study have demonstrated the following. Every intervention that we take to lower the risk of atherosclerotic cardiovascular disease also reduces the risk of dementia. And that means Alzheimer's disease, vascular dementia, uh which are the two main ones, but also other forms of dementia. So, that means having better metabolic health, having lower apoB, having lower blood pressure, not smoking, those things dramatically reduce your risk of cardiovascular disease, and they dramatically reduce your risk of Alzheimer's disease. Now, an area where dementia has an even bigger positive impact in intervention than cardiovascular disease is with that of exercise. So, it's no surprise that exercise improves a person's odds of not getting and or surviving cardiovascular disease, cancer, dementia. But I would say that the evidence for the benefits of exercise are both greater in magnitude and greater in um confidence when it comes to the prevention of neurodegenerative disease. So, um you know, it's it's interesting cuz I do think that many people fear dementia more than any other condition. Um and there are very obvious reasons why that would be the case. Um and it might be that in our practice, we're a bit more optimistic than most based on just the nature of what we do and um the you know, the types of people that are in our practice, meaning like, you know, people who really study prevention um and and really look at kind of these early early signs of dementia and looking at you know, and look at how, you know, specific interventions can
you know, specific interventions can make a difference. Um but unfortunately, um the flip side of that is that of all the chronic diseases, um the the dementing uh and neurodegenerative diseases are the ones for which we have at this time virtually no viable therapeutic options. So, the real name of the game with uh neurodegenerative diseases, but specifically the dementing diseases, and the only other one I'll really mention here briefly is Parkinson's disease, uh because it's the most prevalent movement disorder, is that avoiding them is the first, second, and third priority on a list of three priorities. Um once we get into treatment land, um at least at this point in time, it's not very promising. Um so, these are both diseases where having as high a reserve as you can make a big difference. So, the higher your cognitive reserve and the higher your movement reserve, the more resilient you are to the effects of these conditions. I think I should just state at the conclusion here that, you know, we we should we shouldn't ignore the fourth horseman, which is of course this the spectrum of metabolic diseases. As I said kind of at the outset, I mean, I I think along with cardiovascular disease, we really have a pretty clear sense um mechanistically of what's driving this. I mean, this appears to be primarily a consequence of overnutrition. Um so, energy imbalance is really the driving factor of insulin resistance, and insulin resistance is really the driving factor of the downstream effects that ultimately lead to everything from fatty liver disease, type two diabetes. And again, these diseases in their own right are are quite harmful and devastating, um but their their real uh
devastating, um but their their real uh danger of them is the effect that they're having on the other three horsemen, where they're increasing your risk by, you know, 25 to 50%. So, they really are gasoline on the fire of the other diseases. And the last kind of foundational question before we get into tactics would be, we just talked so much about prevention and the importance of it, which if anyone who is younger listening, hopefully encourages them to kind of play that longer game. But what about someone who's older? So, they just heard you talk about prevention, the importance of it, and they might be thinking themselves, you know, I wonder if it's too late for me to start thinking about my longevity. What would you say to that? Well, I mean, I think there's like the theoretical answer and the practical answer, right? I mean, I think the theoretical answer is while you still have, you know, breath in your lungs, it's not too late to do something. But I also think um that we're all in a car driving towards the edge of a cliff. And it's a lot easier to slow the car down and make sure that you either avoid the cliff altogether or at a minimum, you know, slow your route to the cliff's edge dramatically if you begin the slowing process before you get there. In other words, everybody understands that when you see a red light, you have to be applying the brakes before you reach the actual light. So, at some point, I think it is very difficult to um to to back out of a situation, but I also think that that's the rare exception and not the rule. So, uh you know, I I've even in the book written about uh individuals who are in their 70s
uh individuals who are in their 70s before they take their first committed step towards health. And these are individuals that in their 80s now are doing better than they were in their 60s from a health perspective, from a movement perspective. So, um I would absolutely hope that a person listening to us in what might be thought of as their twilight years, who's thinking, "Man, I wish I did something about this sooner. Is it too late?" I would say it's not too late. Um you'll have to make concessions. You need to start slower. You need to make sure you're not getting injured. I mean, there's an entire playbook, and we actually have a podcast around this episode this topic specifically around, you know, what what would an exercise program for the elderly look like? Um but, you know, I definitely would be um very disappointed that if I if anyone thought I was communicating that uh once you reach a certain age, it's sort of all bets are off and, you know, So, moving from health span lifespan to now the tactics, um I think we'll go through each of them, but I think it'd be helpful at the outset if you just kind of list what the five tactics in your {quote} longevity toolkit are. Yeah, I just kind of list things into buckets, right? And this is not I wouldn't say this is collectively exhaustive. Um there are other things that I think matter that don't warrant a bucket in my view, or maybe I should come up with a sixth bucket that I would put every other thing into, and we could talk about that as well. But, the big five buckets are nutrition, exercise, sleep, pharmacology, and emotional health. And again, we could talk about a sixth bucket which would be pollution, uh temperature, you know, radical temperature exposure,
temperature exposure, um accident avoidance, right? So, behaviors to avoid, you know, harmful accidents, automotive accidents, things like that. So there's like there's definitely also like a a grab bag sixth, you know, column that you could include if you wanted to. But, when I but I mostly talk about the the first five. And we'll start with your favorite, which is not ironic in that statement. It is actually your favorite, which is exercise. And so, I think what would be helpful is you've talked about this before, but this kind of framework of the Centenarian Decathlon, do you want to just quickly state what that is? Because I think it kind of gives some grounding and foundation to how you think about exercise compared to how others may talk about it. Yeah, so there's so much I could say about this. I really thought you were going to throw me the usual ball and start with nutrition, which of course is not my favorite, but we will talk about it. Um but you're right, exercise is my favorite, and it is my favorite um because I think the data are very clear that exercise, if leveraged to its capacity, has a greater impact on your lifespan, that's Remember, that's the how long you live piece, and your health span, that's the how well you live piece, than any of the others. With the only exception potentially being emotional health, right? So, there you know, there's clearly going to be the case of the individual whose emotional health is in such ruins that until that is addressed, no amount of physical health matters, and in fact, any uh anything else is just prolongation of agony. But, if if you exclude that case, which is I don't want to minimize that case cuz I think there are many people who um have been in that situation. Um exercise really is the king of of interventions.
interventions. So, you alluded to something that is one of my favorite um topics, which is called the Centenarian Decathlon. So, uh and again, I I realize that some people have read the book and they understand what this means, or they've heard me talk about it. But again, the purpose of this podcast I think is to make sure that someone who's new um maybe maybe gets up to speed on this, or it's a refresher for someone. So, um the Centenarian Decathlon is an idea that came to me in the summer of 2018. Um and it's uh it's an idea that occurred in an instant, but it was really the result of many years, uh probably four years of suffering, uh so to speak. So, the the suffering started in at the end of 2014 when I decided to stop competitively cycling. And not only did I stop cycling, but I was not going to go back to any other sport. So, I was not going to be competing anymore in Masters swimming, cycling. Obviously, I had no desire to go back and compete in boxing or martial arts or anything like that. Basically, I was done competing, and all I wanted to do was exercise for the sake of exercise. And this, for me at least, was a bizarre, foreign idea. Because from the age of 13 until that point in time, which was 41 or 42, I had never trained without a specific purpose. Every single rep, every single lap, every single pedal stroke, everything I ever did was always geared towards a purpose. And um now for the first time ever, I was kind of like, "Huh, what should I do today? I guess I should go for a run. Okay, I guess I'll lift weights tomorrow. I'm in the gym lifting. What am I lifting for? Well, I used to do this. I guess I should still do this." You know, but it was like this
do this." You know, but it was like this totally rudderless existence that I had. And it stayed that way until the summer of 2018 when I was at the funeral of the parent of one of my best friends. And um again, I I apologies for repeating this cuz I do write about this in the book, but basically, at that funeral, I realized that while my friend's uh mom had died at a relatively old age, I think about 89, um her physical life had basically demised so significantly in the past decade that her actual death was almost just a matter of uh formality. But, she had lost the ability to do the things that mattered to her most a decade earlier. So, she couldn't play golf anymore because of her shoulder. She couldn't garden because of her knees and hips and back. I mean, she just couldn't she couldn't even play with her grandkids. Um and so, she spent most of the last decade of her life largely uninvolved in anything. And um you know, did come down with dementia in the final year of her life, and that's what ultimately took her life. But, um you you know, uh I I was just totally blown away by this person that I once remembered as being completely vibrant losing everything and spending this last year um in this state, and I realized in that moment, as I literally sat in a church pew, first of all, this is really common. And secondly, this is what I want to train for. Like I for the first time in four years realized, "Aha, the thing I want to train for is to avoid this. I want to come up with an event, an athletic event, that will be done at the
athletic event, that will be done at the end of my life, and everything between now and then will be training for it." And so, I just came up with this idea called the Centenarian Decathlon, not because it implies that one has to live to 100 to compete, or not even to imply that it has to have 10 events, but simply as a mental model to say, "What are the most important activities, both activities of daily living and activities of performance, that I want to be able to do at the end of my life? And how well can I define them? How well can I understand the physical traits that will be necessary to execute them? And then, how much can I reverse from there, or backcast from there, what I need to be doing today to increase the probability of doing those things tomorrow to the highest level? And that has become obviously a huge obsession of mine, as you know, uh I, along with a couple of other folks, have started a company around this called Ten Squared, which is just geared towards training people to do this. Um and I think that it is at least until someone shows me a better idea, the best model for how to train if your goal is not something very specific. So again, if you came to me and said, you know, I know how much you love jujitsu. If you're like, look, I there's this tournament coming up in 6 months and I really want to compete for it. That's not the Centenarian Decathlon. That's a very specific type of training you need to be doing in jujitsu to go and compete there. If, you know, my wife is running the Boston Marathon next year and she wants to, you know, run a certain time, she will have nothing to do with training her Centenarian Decathlon. She is going to be doing very, very specific running workouts to make sure she hits her goals. So, there are lots of other ways to train,
there are lots of other ways to train, but my point is that most people aren't training to be the best at their local jujitsu tournament or to run their PR at the Boston Marathon. And even if they do those things, they're usually fleeting. And ultimately, what people really want to be training for is to be the most kick-ass versions of themselves in the last decade of their life. And, you know, again, if that means your 80 to 90 years are functioning like you're a really good 70-year - old, that's a totally different experience from what most people go through. And so, let's say someone is training for the Centenarian Decathlon. So, they kind of agree and they say, you know, I want to put all my focus into this, which is how do I become like an athlete focused on life. Um and we don't have to get into these in detail because in the show notes, we'll link to the multiple, multiple places we've talked about them. But what are the four components that you think are important for someone who is interested in training for the Centenarian Decathlon? It starts on the foundation, right? You have to have stability. You have to have the chassis. Um and that, you know, bring Basically, I'd say the chassis and the tires, right? So, you have to have every aspect of the motor control, coordination, ability to dissipate force, uh ability to receive force, um ability to balance, motor you know, there's so much that goes into stability that it I think got a a full half chapter in the book. Um and it's far and away the most complicated to explain, but it's really obvious to see it when it's not there. So, you know, this is every one of us is lacking in stability and it was the biggest re-education for me as I pivoted to this way of training. Um so, it's it's everything from
Um so, it's it's everything from learning how to appropriately pressurize your intra-abdominal space to how to um unlock your ribs, maintain an appropriate center of gravity, how to be able to isometrically contract muscles as necessary, how to be able to do it under control, how to have good foot mechanics, right? I mean, all of these things we've done dedicated podcasts on because each component of this stability game is is quite nuanced. Um and the good news is while most of us show up to the middle part of our life with enormous deficits here, they're all retrainable. We're we're actually still quite plastic in our old age. Second component is strength. Um and I would say a subcomponent of strength is power. So, even though we lose power very quickly as we age, the more we can maintain it, the better. And you can't have power without strength and stability. Um the third component, uh and this is really more of a continuum. The third and fourth are part of a continuum of cardiorespiratory fitness, but we think of this, you know, I talk about this as being a triangle. So, the base of the triangle is the aerobic efficiency. So, this is the, you know, maximum fat oxidation ability This is your all-day pace. We want that to be as high as possible. And then the peak of the triangle is the VO2 max. That's, you know, most adequately thought of as the engine size. So, that's the peak aerobic output. So, those are the four components. And one of the exercises we do with both our patients and then and the obviously the clients in 10 Squared is once you have a person's Centenarian Decathlon goals, you break them down into what is required. So, if you give me your list and you, you know, we can take that list and we can say, oh, this requires a VO2 max of 31 ml per kilogram per minute. This requires an ability to sit this, you know, this way or this requires this much strength
way or this requires this much strength in this domain. This requires this type of hip loading, etc. And then we can evaluate where a person is today and then say, oh, okay. Well, obviously today you can do all of those things, but here's the predicted trajectory of decline on each of those things and will you be above your benchmarks in 40 years or will you be below them? And for most of us, myself included, uh at least on some of those dimensions, you're actually considerably below them at your target and therefore you have to raise the performance currently to make sure you hit the targets in the future. And like we mentioned for anyone who's interested in further on anything exercise, in the show notes, we'll link to the multiple podcasts, articles, etc. So, people can dive in, but moving from exercise to your second favorite, nutrition, um I think it'd be helpful to start kind of what's your framework for how you think about nutrition because you don't necessarily think about nutrition as some people talk about it, which is this diet's best or this diet's best. You kind of look at it a little bit of a different way. And so, do you want to walk people through your framework and how you assess nutrition and where someone is at in their nutritional state? Yeah, I mean, I would say that nutrition is is a very complicated thing to study. I would say it's the messiest of all the pillars to study, probably even messier than emotional health, although maybe that's debatable. But, um you know, the reasons for it are obvious and not worth restating, but it's for that reason that there are very few things that can be stated in this field with a high, high degree of certainty. So, unfortunately, the challenge in nutrition is you have a lot of people that speak with such insane conviction and they talk about something as though it is absolutely correct even though if you were putting an error
even though if you were putting an error bar on their statement, it would dwarf anything they're saying. And truthfully, I have been guilty of this, right? I think 12 years ago, I was talking about nutrition with a level of certainty that I don't think was warranted. And so, as the adage goes, the further you get from the shore, the deeper the water. And I think in my older age, I'm actually quite far out from the shore and I realize the water is awfully deep out here and there aren't a lot of things that can be stated at a high enough degree of certainty that you should act on them with, you know, almost blind faith. So, here are the two that I can tell you with a very, very high degree of certainty. The first is that the single most important input from nutrition to a person's overall health is energy balance. Stated another way, the energy input of food is the first-order determinant of health. Maybe stated another way, the total calories you consume would be the most important thing. Not the only thing. I do not want to suggest that 1, 000 calories of Tic Tacs is the same as 1, 000 calories of broccoli. It is not. But I'm also talking about this through the lens of common sense. And the truth of it is, if you subside on a diet of Tic Tacs, you're going to eat a lot more than 1, 000 calories of them because they're not satiating and they're junk and they're hollow. So, I want to be very clear that the primary input is total energy, but it is also impacted by many other things, including diet quality, processing, and
diet quality, processing, and macronutrient distribution. The second thing that is abundantly clear is that protein is the macronutrient we should be least flexible on. Stated another way, we can be quite flexible on how much carbohydrate and fat we consume to fill our energy needs. But because protein is not consumed for the purpose of ATP generation, which is the principal reason we consume carbohydrates and fats, although fats are also essential for some structural purposes, we cannot be too flexible or compromising in our protein requirements. In other words, if you really wanted to just come up with a single number to give people, I would say on average about 1. 6 g of protein per kilogram of body weight should be consumed by everybody. Now again, I hate saying that because there's truly nothing that you can say across the board. There are clearly people who, based on what they're eating, will need more protein and there are probably people who can get away with a little bit less. You know, if you took a perfectly high quality PDCAAS 1. 0 protein in a person who's not over the moon active, they could probably get away with 1. 2 g or even 1 g. But boy, anything below that and you're starting to really miss out. And by the way, as you age, that those requirements go up due to anabolic resistance. So, again, we can talk all day about every diet under the sun and every religion and every faction of every religion around every dietary tribe. But the truth of it is it's really hard to find a scientist, an actual nutrition scientist. I'm not talking about an influencer. I'm not talking about a health blog. I'm talking
talking about a health blog. I'm talking about actual people who work in labs doing nutrition who will kind of disagree with that statement. There are some, but they are in the huge minority and interestingly they tend to avoid using human data when they talk about those things. But when you limit yourself to the species of interest, which is humans, not rodents, and you talk about experimental data coupled with, you know, other insights, those two things seem to matter the most. How many calories are you getting? Not too much, not too little. Are you getting enough protein? Um obviously there are other terms. We certainly want to make sure you're getting enough micronutrients as well and that you're avoiding toxins. That tends to be less of an issue today than it was 100 years ago. Um but of course that's also really interesting. Um but a lot of the other stuff, Nick, is details, right? So, uh when I'm looking at a patient given how important those things are, to me it makes sense to be evaluating those things at the outset. So, when we do a DEXA scan on somebody on day one and we can see how much subcutaneous fat they have, how much visceral fat they have, how much muscle mass they have, and we can do a lot of advanced blood work and see how metabolically healthy they are, how well they dispose of glucose, all these other things, I can very quickly answer three questions. Literally, on first contact. Are you overnourished or undernourished? And that really comes down to energy balance. How much fat do you have on your body and how well is it distributed throughout your body? Where is it distributed? Second question, are you adequately muscled or are you undermuscled? Third question, are you metabolically healthy or not?
healthy or not? And when you can answer those three questions, which you can in a very short period of time with a relatively small amount of data, that tells you, does this person need to eat more, less or the same total energy? The same amount of protein or less? And how important and what type of exercise should they be doing to augment our findings? Now, because we're talking about nutrition, I'll close this out by saying most people when they do this come out slightly in the overnourished category. That's just another way of saying most people are overweight or obese, right? I think the numbers are probably 70% of the population are overnourished or significantly overnourished. Therefore, most people when you go through that whole treatment algorithm are going to be in the I need to eat less camp. If you are in the I need to eat less camp, you now have three ways to do that, three strategies, if you will. The first is directly reducing caloric intake. So, that says agnostic to what or when I eat, I will simply eat less. This is the most direct way to do it. Um it has lots of plusses and minuses which we have discussed in so much detail in other podcasts that we'll link to. The second method is I will identify something or some set of things in the diet that I will remove from the diet. I will restrict them. This is called dietary restriction. And the more restrictive the elements of your diet, the more effective this technique is. So, if you only choose to restrict lettuce, this will have no effect. If you restrict everything but potatoes, meaning if the only thing you allow yourself to eat is potatoes, this will have an enormous effect. So, again, the more you restrict, the better that
the more you restrict, the better that works. And then the third strategy is time restriction where you limit the window in which you eat and the narrower and narrower that window, the greater the likelihood that you will overall induce a caloric deficit. So, you know, there's a lot more I can say about nutrition. We could get into the nuances of which type of fats are better, saturated fats, monounsaturated, polyunsaturated fats, is a Mediterranean diet more efficacious than a low carb diet or a low fat diet? And again, all of those things again, I've written about, I've spoken about, but but I think from from the standpoint of like what are the most important things, I think that's I think you've got it. Have you remembered what you ate for lunch yet? That's I think the only thing from the nutrition conversation that's missing. I scarfed down some leftover spaghetti squash that we made yesterday and what else did I have? Oh, I had a uh uh like a container of uh blackberries and I had some venison. There you go. Great. Um moving on to sleep. So, sleep is something you've written about where you take it much more seriously now than maybe you used to in the past. So, do you want to talk about why you think sleep is such an important component of not only lifespan, but also healthspan? You know, I think the data really make the case more compellingly than than I need to. Um there's just uh you know, again, fortunately short-term sleep deprivation is easy to study um and it unequivocally demonstrates uh a remarkable uh negative impact on cognition, on physical performance, on physical markers of health such as insulin resistance, on appetite. Everything that can go wrong in the human body goes
can go wrong in the human body goes wrong when you are sleep deprived. Um and again, what's nice about this is you don't need to do five-year studies to figure this out, right? You can do two-week, three-week studies where you take people down to 4 hours a night of sleep and you can absolutely destroy them in every physiologic measure during the wakeful period of their lives. So, we can then extrapolate from there that, okay, well, if you're only sleeping five and a half or six hours a night, you're probably not getting as much of the negative effects, but when we see and measure other effects that are negative to a lesser extent, it seems pretty easy to attribute them to the reduction of sleep. So, in other words, um when you look at a person who's, you know, not sleeping as inadequately as people people are typically studied in short-term studies geared towards identifying the risks, um they get many of the same problems, but just not as extreme. Um suggesting there's a dose effect to sleep reduction. Um and you know, truthfully, I think that um this is something that I think society is far more willing to entertain today than 10 years ago. Um I think, you know, Matt Walker, uh who's who's also a very close personal friend, has had a lot to do with this. Uh Arianna Huffington has brought a lot of attention to this. Um so, I think there are many people out there that are saying, "Hey, this whole idea of I'll sleep when I'm dead, which used to be my mantra, uh is like, yeah, you're going to be dead quicker if you adopt that mantra. So, you will indeed sleep when you're dead and you'll be dead sooner than you want to be. So, um again, I think that, you know, this this one doesn't require a lot of convincing. Um
Um Um but how to do it, of course, is a little more complicated. Um the good news is there's really a lot of wonderful behavioral tools. Um and ultimately for some people, you know, pharmacology or mechanical assistance such as CPAP, you know, if a person has apnea, there there are technologies both pharmacologic and otherwise that can really help here. But for most people, uh the behavioral tools do the work. Um this is really one of those things where very few people need to see a physician to help them sleep or to troubleshoot a sleep problem. And when you do, fortunately there's an entire branch of medicine dedicated to sleep physiology. There are actual physicians who specialize in this and um we're certainly not afraid to use them when it's necessary. There's also a field of behavioral therapy called cognitive behavioral therapy for insomnia that is an entire discipline that is dedicated towards the cognitive tools that you can use during periods of insomnia. So, um you know, we always get patients in our practice um who just have what can only be described as the most abjectly horrible sleep. And I just of all the problems we face, this is the one that I tend to be most optimistic about our ability to help in a relatively short period of time. And we have a whole AMA dedicated to sleep along with multiple Matt Walker episodes. So, I don't think we needed to get into insane detail cuz we will link it in the show notes. But, you mentioned a few of the behavioral tools. And so, if someone says, "Okay, I need to take more awareness of my sleep. I need to do more to get better sleep." What are some of the things that they can look at and evaluate? I would say if you were you know, if we were in an elevator and we had only between the first floor and the 15th floor for me to tell you everything that mattered, I would say uh try to go to bed at the same time and wake up at the same time every day. Give yourself about
same time every day. Give yourself about 8 hours to be in bed. Make the room as dark as possible, as cold as possible. And detach yourself from anything stimulating, especially kind of upsetting, which is you know, work, social media, that kind of stuff, for 2 hours before bed. And if we haven't hit the 15th floor yet, I would say try to not eat or drink any alcohol for 3 hours before bed. Those would be like the no risk, no regret moves to try to fix your sleep. And that's a lot, by the way. Like, I I'm not suggesting that would be easy to do for someone who's doing none of them. Um but if a person if you gave me 100 people who were complaining of poor sleep and or objectively had measurements of poor sleep and all 80 of them did that uh pardon me, all 100 of them did that, I think 80 of them would get better. Moving to drugs and supplements. This is something that, you know, if you look at all the different drugs, pharmacologic, if you look at all the supplements, we have an insane amount of content on. Um impossible to answer all the questions here that come in. But, I think helping people understand just what their relationship with drugs and supplements should be, how they should think about it, how they should not think about it. You know, how do you talk to patients about that who come in to the practice and maybe have a list of 20 supplements that they show up with? Well, I mean, yeah, that's definitely one phenotype. But, I I would say just to kind of address both extremes, right? You have some people who think everything is solved by drugs and supplements. Um and then you have people who think you should never take a drug or a supplement. Um and so, I just always kind of try to remind people like drugs and supplements are just a tool. It's it's like to say I never want to take a drug is kind of like, you know, telling a contractor, "Hey, please do a good job building my house, but just never use the hammer." Um or never use the Phillips screwdriver. You
never use the Phillips screwdriver. You can use the Robertson, but not the Phillips. Um you just want to have tools. We just want to have tools. And the best contractor and carpenter and tradesman is going to have the most tools and the most facility with knowing how and when to use them. So, um that said, we do kind of, especially on the supplement side, have a framework because as you said, there's a in an infinite number of supplements. There's a finite number of regulated drugs, but a non-finite number of supplements. So, you have to have a framework for this thing, right? And so, the first question I'm always asking myself with any exogenous molecule is is this a molecule that is being taken to lengthen lifespan or improve healthspan? You would be amazed at how many times I ask somebody who's taking a supplement which of those two they're taking it for. Usually, you get a very blank stare. I'm taking it because fill in the blank influencer told me to take it. Okay. So, let's say we can establish that you were taking this for one of those reasons. It's either going to make me live longer and or it's going to improve my physical, cognitive, or emotional health. The next question I would say is, "Okay, if this is a lifespan enhancer, if this is going to make you live longer, is it doing it by targeting a specific disease or is it a broad geroprotective molecule? Similarly, if you're telling me this is a healthspan enhancer, is it specifically enhancing cognitive health, physical performance, emotional health? Okay. Uh or is it sort of acting through some mechanism we don't understand?" I would ask if we have safety data on this. I would ask if we have efficacy data in humans and or in animals if not. And if in animals, how how relatable is it? If it's a supplement, I would ask, "How can we control for purity?" Right? How
can we control for purity?" Right? How do we know that what's what the bottle says is in it is actually what's in it and that nothing that's not supposed to be in it isn't in it? There are a few more questions, but that's the long and short of it. And and so, I I think um one needs to go through that type of exercise and put that type of filter to everything. And and then and only then I think should we go down the path of, "Okay, you know, what supplements do we want to use, you know, where do we want to turn to pharmacology, hormones, those things?" And moving to the last kind of tactic. And you talked a little bit about this cuz, you know, emotional health fits in the healthspan bucket as well. But, you know, when people think about longevity, emotional health is not something that usually comes up a lot. And so, what would you say to someone who maybe is taking the steps in their nutrition, their exercise, their sleep, you know, drugs and supplements, but not necessarily focusing on their emotional health? What would your advice to them be on how emotional health, you don't necessarily correlate it all the time with longevity, but you find it to be an important aspect? Well, I mean, I think there's two components. I think there is enough evidence um though you could never prove it that um that, you know, a person who's um managing their stress better, who's happier, and who has better relationships probably also lives longer. Uh certainly the epidemiology suggests all of that. That's not unclear. Um but but I'm acknowledging that that would be very difficult to demonstrate causality, right? There could be, you know, people could be happier and have better relationships and all those things because their health is better. So, it could be reverse causality there. But I think there's actually enough evidence that there's at least bidirectional uh causality there. But, I think to to help somebody think about this, I would say just forget that. Let's pretend
Let's pretend that being miserable, lonely, and angry helped you live longer. And that if you were happy and you had great relationships and you were in harmony, you would live shorter. Who would choose the former when you frame it that way? Right? I outside of extremes like, "Okay, happy people can't live past 30, miserable people can live to 100." I'm sure a lot of people would say, "Well, I'd rather be miserable at 100." But, the the truth of it is like even framed that way, it seems ridiculous, right? So, all of that is to say as a thought experiment, just forget the lifespan piece of this. Just think of it through the lens of common sense. Why would you ever choose to be unhappy? It doesn't make sense. And I think what maybe for me was a big insight late in life was you can do something about this. You you it's not you know, um everybody's got a story, everybody's got a history, everybody's got a background that brings them to the table. Um but, it's all modifiable, right? So, the software can be modified is the point. And um you know, again, we've got so much content on this that I I obviously couldn't go into it in any de - detail here. But, um you know, I think the most important thing for the purpose of this discussion is that this entire area is as important, potentially more important, than all of the others because without this one in check, the other ones don't matter. And Peter, I think that kind of wraps what we were hoping to cover. And again, as we kind of mentioned on the outset, the idea is not to get into the super intense details on everything. We'll link to that, but more so cover high-level kind of longevity 101, how you think about some core aspects for people who are newer, people who need a
people who are newer, people who need a refresher. I think the last thing that I we should end with is just if someone is new and they're listening to this and they maybe feel a little bit overwhelmed on where they should start, right? A lot of information came out of them on the lifespan, healthspan, different diseases, different tactics. You know, what advice would you give someone who is listening and they would say, "You know what? I I want to take this more seriously, but I'm a little overwhelmed on where to start." I would say just pick one. Yeah, I think it's um it's not a race. And um I think finding something that you think you're going to be successful in would be the best first place to start. So, if after listening to everything we just talked about, you're kind of like, "You know what really resonates with me? My sleep probably sucks." Then I would say, "How about you change nothing in your nutrition, nothing in your exercise, don't do anything else, don't buy a supplement, just work on implementing the stuff we talked about on sleep. Because if you get that better, it's going to do two things. It's going to make it easier for you to address the other things and it's going to give you the confidence and agency that says, "Hey, I actually have control over this thing. It's not out of my hands." Awesome. Well, Peter, hopefully people enjoyed this special episode, but thank you for your time and we'll see you on the next one. Sounds great.
Transcript auto-generated by YouTube. Verbatim — duplicates intentionally preserved.
The marginal decade is a useful lens: imagine the final ten years you want, then train and live in a way that makes that decade more likely. It turns longevity from abstraction into design.
Cardiovascular disease, cancer, neurodegeneration, and metabolic disease build over years. Prevention works best when it begins before symptoms demand attention.
Aerobic capacity, strength, stability, and power each protect a different form of independence. Together they create a body that can carry you through ordinary life with less fragility.
Sleep, emotional health, and nutrition are not supporting details. They regulate appetite, glucose, repair, stress chemistry, and the discipline needed to keep a practice alive.
The goal is not simply more years. It is more capacity inside the years we have.
Define the physical abilities you want to keep late in life.
Train across aerobic fitness, strength, stability, and power.
Use labs, family history, and habits to find risk early rather than waiting for disease.
