Listen to Episode

Read Episode Transcript

Hello everyone! Today I'm speaking with Physician Bongevity Expert and now author Dr. Peter Adia. We discuss his new book Outlive, The Science and Art of Bongevity, and explore the immense benefits that can be gained from exercise in just three hours a week. How small imbalances in diet can cause major problems such as diabetes and obesity, the difference between lifespan and health span, the sourd reasoning behind the American food pyramid, and the scientific side of alternative diets. No buzzwords. Looking forward to the discussion today. Dr. Adia in your book, you talk about lifespan in general, but you also concentrate on a concept called health span, termed health span, and you're concentrating more on decades, let's say, of healthy life rather than absolute length of life. Do you want to expand on the concept of health span and why you distinguish between that and longevity per se? Yeah, longevity is really a function of lifespan and health span, so life span is the easier of those two to understand because it's binary, you're either alive or you're dead. And I think when most people think of longevity, they think of the elongation of lifespan understandably. But that's really only part of it. The other part, the part that might actually be more important to most people when pressed on the issue is health span, which is the quality of life. And the medical definition of health span is not a particularly helpful definition in my view. It's effectively the period of time from which you are free of disability and disease. But I don't really think that captures what health span is to most people. And so I think health span is a broader concept. And it's not binary, it is analog, but it really constitutes some measure of cognitive health, physical health, and emotional health. And at least two of those are intimately linked to age, which is to say they generally decline with age. But if we focus, I think, relentlessly on the pursuit of those things, we tend to get a better quality of life overall. And by the way, you think you get for free a lot of lifespan benefits. Right, so well, it's very important to get the definitions and the measurements right because systems optimize to maximize their score and what they're measured by. And I suppose living to 140 wouldn't be so good if you were senile for the last 70 years and institutionalized, for example. And so it sounds like when you talk about health span, you're intermingling to what would you say to quality of life issues. One would be the expansion of youth rather than longevity per se. And then something associated with the existential quality of life. So maybe we could start with, well, does that seem to capture the interaction of those two things seem to capture what you're talking about with regard to health span? Yeah, I think so. I think that the cognitive and physical piece are the pieces that do decline with age and we want to preserve those as long as possible. And we can be very specific about what those things are, by the way, right? We could drill into what is cognitive health span, what is physical health span. And then that other one that is not so age dependent might be at least as important and probably frankly falls much more into your wheelhouse than mine, professionally at least. And that is about the quality of a person's life and the quality of their relationships, their sense of purpose and things of that nature. The content I've created over the past year represents some of my best to date as I've undertaken additional extensive exploration in today's most challenging topics and experienced a nice increment in production quality courtesy of Daily Wire Plus. We all want you to benefit from the knowledge gained throughout this adventurous journey. I'm pleased to let you know that for a limited time you're invited to access all my content with a seven day free trial at Daily Wire Plus. This will provide you with full access to my new in-depth series on marriage as well as guidance for creating a life vision and my series exploring the book of Exodus. You'll also find there the complete library of all my podcast and lectures. I have a plethora of new content in development that will be coming soon exclusively on Daily Wire Plus. Voices of reason and resistance are few and far between these strange days. Click on the link below if you want to learn more and thank you for watching and listening. Yeah, so a long while back I was looking at interventions to improve people's lives and I knew at that point that cognitive decline was a major problem, especially in terms of productivity and general competence. It's pretty pronounced linear downhill trend on the fluid intelligence front from about the age of 25 forward and that can decline precipitously in say late 70s, early 80s, especially with the onset of degenerative neurological diseases. I was looking at the literature on cognitive remediation. This is back in the times about 10, 15 years ago when there were a lot of online sites that purported to run you through cognitive exercises that could increase or maintain your IQ. There's never been any evidence for that by the way. It's a pretty damned dismal literature. But what I did find and I think this is extremely solid is that if you want to maintain your cognitive function that both cardiovascular exercise and weightlifting seem to do a pretty damn good job and maybe that's because the brain is such an oxygen demanding organ and other obviously energy, it's energy demanding and resource demanding in other ways. If you can keep yourself cardiovascular fit interestingly enough, that's the best pathway to cognitive health. Then I was looking on the psychological side, you know. What I found was that there were interventions that help people get their story straight of course psychotherapies, one of those, but there are written interventions. If people write about their past, about their past traumas and if they write about their future plans, they reduce general uncertainty. That reduces their stress and that seems to produce a relatively pronounced physiological benefit. And so there's an interesting interplay there that we can talk about more in terms of the emotional and the physical. It's pretty funny that if you want to improve your cognitive function or maintain it, you should exercise rather than think and that if you want to improve your physiology, you should straighten out your story and face your traumas rather than say exercise. So what do you recommend in your book, you know, live in particular with regard to the expansion of health span? What do you think and how do you practice this personally? What do you recommend to people? So I think that exercise is empirically the most valuable tool we have for both the cognitive and physical components. So let's start with the cognitive because I think here it was less intuitive. So about 10 years ago when I really went down this rabbit hole, I had one of my research analysts spend a lot of time going through the literature. So we created a framework where we were going to look at every single intervention and how it impacted executive function, processing speed, short-term memory, long-term memory. Those were the four metrics we cared about because as you point out, those are all bits of intelligence that decline with age. So and I we looked at everything. Okay, so we looked at every molecule, we looked at every possible thing that you could think of. And after about nine months of this, the thing that stood out above all else, beyond any diet, beyond the importance of sleep and other things that certainly mattered controlling blood pressure, lipids, etc. was exercise. And I even though I was a lifelong exercise or in love to exercise, I just couldn't believe it. It seemed so trite that exercise could have such a profound difference on the state of cognition, not just in terms of its performance is effectively a no-tropic, but also in its ability to delay, if not outright, prevent dementia. So once we dug into the mechanisms, I think it became clear why exercise is so potent. And it's basically that it is acting on so many different levels. So as you pointed out, it's acting at a metabolic level. The brain is such an energy demanding organ. As you know, and maybe your listeners do, it weighs about 2% of your body weight and it's responsible for 20 to 25% of your energy consumption. So therefore, anything that disrupts that is catastrophic. So when you look at the improvements in glucose, disposal, insulin sensitivity, and all metabolic parameters, exercise is the most important tool we have there. When you look at the reduction of inflammation, vascular health improvements, again, exercise stands alone. When you look at the production of neurotropic growth factors such as BDNF, again, exercise is basically a drug for neurons. And so I think I eventually came around after a year or so to realize that, again, as simple as it sounds, exercise is such a potent tool. And you look at the brains of people who exercise a lot, and you can see far less damage, not just microvascularly, but in terms of brain volume loss over time. So let's talk about exercise from the perspective of a behavioral psychologist. So one of the things you learn as a behavioral psychologist is that it's very difficult for people to change their attitudes or their actions and it's very difficult for people to change their lives. And so, and we all know this because we might tell ourselves, for example, to exercise. And we might be well supplied with arguments for why that's a good idea. But that doesn't necessarily mean that we learn how to incorporate and exercise routine into our life. And often the reason for that, there's many reasons, I mean, exercise is difficult and that's one reason. But it's also often the case that people don't form a strategy and break the problem down into steps that are simple enough to actually implement. So they think things like, well, I'll go to the gym two hours a day, three times a week, and I'll start that next week. And truth of the matter is, they don't have six hours to spend and they can't tell themselves what to do anyways. And so, what you do as a behavioral psychologist is you look at the simplest possible change that produces the maximum possible benefit. And so, for example, if people are listening and they want to begin to implement an exercise routine, like, what about a daily walk of 10 minutes in the morning? Like, where would you start someone? So it completely depends on their baseline. But based on your question, Jordan, I'm going to take it as we're talking about someone who's doing no exercise. Yeah, let's start with them. Yeah. So the good news is, first of all, and I accept the fact that not everybody is swayed by data, but I at least want to put it out there. So if you're a person who's in the doing zero exercise per week camp, the very good news is the benefit you get from going from zero to three hours a week is a greater benefit than anyone gets along the exercise curve. Right? So, taking someone who's at five hours and taking them to 15 will produce less relative benefit than going from zero to three. So in other words, I want that person to see some real incentive for making this change. Secondly, I'll put some numbers to it. Right? So going from no exercise to three hours a week, approximately reduces your cause of your all-cause mortality, that is to say, death by every cause by 50% at any moment in time. So if you're standing there asking, what's the probability I'm going to die this year? Well, we can sort of actuarially figure that out. You get to cut that number in half by simply going from zero to three hours exercise a week if you're a non-exerciser. So again, there's going to be a subset of people for whom that's a very powerful piece of information they didn't know. So then what I would say was, how do you do that? So I agree with you that you're much better off trying to do 30 minutes, six times a week, than three hours once a day, or two hours in whatever fashion. So what I would say is the most effective way to do that is probably about 90 minutes of low intensity cardio. And for a person who's not particularly fit, that's going to amount to just brisk walking. Rather than tell them what to do, I tell them how to feel when they're doing it. So what you want to feel is out of breath enough that you can barely carry out a conversation, but you could if you had to, but not so out of breath that you can't carry on a conversation, and not so easy that you can speak easily. So there's that sweet spot in there physiologically, we call that zone two, but I'm not going to bore them with that nomenclature. It's just basically 90 minutes, say three times 30 or two times 45 a week, where you're just out of breath enough that you don't want to talk, but you could if you had to. That's part one. Right. So you push, push yourself past your slightly past your simple level of comfort. That's right. And so let me push on you a bit with regards to three hours a week again from the perspective of taking someone from zero to to somewhere. What are the benefits, let's say you talked about the benefits of walking something approximating 20 to 25 minutes a day that can be dispersed out in various ways. You also mentioned like two 45 minute sessions or three 30 minute sessions. If someone, what would happen if someone goes from zero to like 10 minutes a day or an hour a week? Where do that benefits of that three hours? Yeah, that's great. That's great question. I don't think we have the fidelity of the data at that level because you generally don't push enough of a conditioning benefit. But I think what you're getting at and we do this as well is you want to separate between the behavior change and the physiologic change. And for some people, and James Clear has written a lot about this, but I think a lot of people have come to the same conclusion with any behavior change. If it's a person who's never done anything, you're right. The answer might be for every day when you wake up in the morning, rather than your normal routine of jumping in front of the computer, I want you to go and walk around the block once. It'll take four minutes. But and so I don't want to represent you're going to get a physiologic benefit from that. You probably won't, but what you will get is you're going to start to reset a behavior, which is, aha, the first thing I do in the morning now is this other thing. And we'll slowly increase that. And at some point, you will get a physiologic benefit. But what we're doing is planting the seed of how to change the behavior. Yeah, well, and you could always expand that over a year. I mean, one of the things another thing I learned as a behavioral therapist, and this seems obvious, but it's not obvious enough so that people think about it or put it into practice is that your life is made up of the very small number of things that you repeat every day. And these are often things that people consider trivial. So for example, lots of people sit down, have dinner with their family every evening, and they don't consider that special. But because you do it every day for an hour, an hour and a half, it's like 8% of your life. So you only have to get 15 of those things in order and you have your whole life in order. Same thing applies to a daily habit. And so if you started, say, walking for 10 minutes a day, well, that's 70 minutes a week. And that's four hours a month or 50 hours or one work week a year. And that's a substantive change. That's about 2% of your life. You're a waking life, something like that, or at least 2% of your awake working life. And so it's useful for everyone listening to understand that small changes that you maintain can be of radical importance. And once you're walking for 10 minutes a day, it's a hell of a lot easier to go to say 12 minutes than it is to go from zero to walking at all. So yeah. So okay, okay. So what do you think? What did you conclude as a consequence of going through the literature with regards to say weightlifting rather than cardiovascular exercise? So in biology, we look to integral functions to give us a sense of how valuable and input is. And you don't get many of them. Okay. So most people are probably familiar with something called a hemoglobin A1c. It's a blood test you get at the doctor. And if it's high enough, it tells you if you have type 2 diabetes. So if the hemoglobin A1c is beyond 6.5%, that tells you that over the past three months, your average blood glucose has been 140 milligrams per desoliter, which is the cutoff for type 2 diabetes. So in that sense, hemoglobin A1c is an integral of your behavior over the past three months with respect to glucose. We don't have a lot of those, but we have two really amazing ones with respect to exercise. One of them is around strength and muscle mass, and one of them is around peak cardio-respatory fitness. With respect to the, so I'll just get to the punchline. The punchline is there is no metric that is more highly associated with living a long life. Just this is purely based on length of life. There's no metric anywhere in the medical literature. It's more highly correlated with this than having a high VO2 max. VO2 max is a measure of your peak cardio-respatory fitness. But the second most highly correlated metric of length of life is a composite metric of strength and muscle mass. So in other words, and why people always ask me why is it so important? I think it's important because those things are remarkable integral functions. VO2 max isn't just a number. Do you want to define the integral? Oh yeah. Yeah. Yeah. So they basically tell you they add up the work that has been done to that point. So you don't just have a VO2 max because you woke up one day and decided to do something positive. You have a high VO2 max because you've been training very hard for a long period of time. In many cases for years. Similarly, a person doesn't just wake up and have a lot of muscle mass or have a lot of great strength. Those things are the product of a lot of work. And I think that's why they are so potent. In fact, they are far more potent as predictors of a long life than all of the negative things you can imagine are predictors of a short life. So when you look at things like smoking, type 2 diabetes, hypertension, even the presence of cancer has a lesser impact on the shortness of your life than those other variables have on the length of your life. Yeah. I've read that grip strength, for example, is a good marker of propensity for longevity while in everyone, but particularly in elderly people. And it isn't as you pointed out because grip strength per se is particularly important, but because grip strength happens to be a good marker for overall, what would you say, psychophysiological integrity? 100%. 100%. Yeah. It's grip strength is one of the most potent. So PIP is way. If you compare the top desial to the bottom desial and grip strength, it's a 70% difference in incidence and death from dementia, all caused dementia, not just Alzheimer's, every form of dementia. When I was in my mid-twenties, when I was 21, 22, I weighed about 130 pounds, 135 pounds, I was six foot one. And so very, very thin. And I spent about three years, four years intensely weightlifting and packed on about 35 pounds muscle. I did eat like a mad dog for about three years to do that. But one of the things I noticed that was really cool was that I also got to be a lot more coordinated. I was using free weights, because free weights help exercise all the little muscles and tendons. But I also, it also seemed to me to be unbelievably useful for facilitating, likely for facilitating nerve myelonization. And I thought then think now that that was probably a good marker. That increase in coordination was probably good marker for improving neurological function. And so, yeah. And as you age, it doesn't get a lot of attention, but sarcopenia, which is the loss of muscle mass, the wasting away that occurs with aging. And again, this begins rather subtly. We lose, you know, what are called type two muscle fibers first. That's the hallmark of aging. So the type of muscle fiber that's responsible for explosive power is the first one that begins to atrophy when we age. Even at my age, I'm 50. I'm already experiencing that to a great extent. I don't have a fraction of the explosive power I had at 25. Once you lose explosive strength, you start to lose overall strength. And once you lose that, you're going to start to lose muscle size is the very last thing. So by the time a person is 75, the decline in muscle size, which is already proceeding strength, is significant. Now, we can do a lot to prevent this. And I think that that's what's being captured by these statistics. The people who are able to delay that loss of strength and muscle mass are the ones that are going to live the longest on average. Yeah. So on the weightlifting front, we talked a little bit about, you know, what you could do simply to start working out on the cardiovascular front. And brisk walking is the simplest and most straightforwardly implementable strategy on that front. I would add one thing to that, Jordan, which is once a person reaches a certain level of fitness, the brisk walk may not be sufficient enough to produce enough cardiovascular stress. Depends where you live. But if you live in an area where you've got a lot of hills, that might not be the case. But for most people, you know, there's a there's a limit in human gate to how fast you can walk. And for most people, it's about 3.5 to maybe up to four miles per hour. And again, at a certain point, that's not going to be fast enough. So what we can do for that individual, rather than have them transition to running, I like to put weight on their back called rucking. So you carry a military type of backpack with plates of weight in the back. And now you without putting additional stress on the knees, put additional stress on the cardio respiratory system. So just throw that out there is additional ways to get this done. Yeah, well, okay, okay. As I said, in my 20s, I worked out with free weights and I have an adjust set of adjustable free weights now. But what what I found very straightforward and actually implementable is to use about a I use about 20, 25 pound weights, depending on how often I'm doing it and run through I run through a set of exercises through my whole body, you know, starting with my calves and moving upward. And I can do a whole workout routine, both two sets of 15 exercises in about 20 minutes. And so for everyone listening, it's also very simple to use to start weight lifting because all you need is a couple of dumbbells. Size is going to depend on, you know, your size and your strength. But you can do an awful lot with with two dumbbells. You can exercise your body in all sorts of ways. So that combined with walking and well, and you added another twist to that. That's not a bad initiation. Anything you add on the weight lifting front? Yeah, I think the other thing that I would say and I think about this stuff all the time. So I have a very elaborate gym. I do, you know, every sort of exercise you can imagine. But sometimes I like thinking and debating with people like what's the single most important exercise you could do if you could only do one. And for the lower body, for the lower body, I think step ups would be so if you had just two dumbbells and a box, you can do anything, right? Because you're going to do forward step up, backward step up, side step up, you can go heavy, you can go light, you focus on the concentric phase, which is the phase of getting up. Concentric is the phase of a muscle when it's getting shorter. But then you really get to focus on how slowly you can step down. So my typical, I'm doing box step ups at least twice a week. I do a count of one up, three down. So taking three full seconds on that one leg to descend. And that's training what we think of as the brakes. So when we age, this is a particular form of strength that deteriorates, which is eccentric strength, the strength that a muscle exhibits while it is getting longer. This is why so many old people fall and the mortality of a fall when you are above the age of 65 is staggering. So depending on the series you look at, 15 to 30 percent of people over the age of 65 who fall and break a hip will be dead within a year of that fall. Of those who survive, 50 percent of them will experience a reduction in class of mobility. So meaning people who walked normally will walk with a cane, people who walked with a cane will walk with a walker, people who walked with a walker will be a wheelchair bound. This is a profound change in quality of life. And a lot of it has to do with a loss of this type of strength. If you think about it, people are much more likely to hurt themselves stepping off a curb when they get old than stepping onto a curb. It's these loss of breaks. So yeah, a set of dumbbells, which you can carry around because that's really a very important piece of upper body strength is being able to carry something. That's where that grip strength is coming from. And being able to do step-ups, step downs, squats, all sorts of things. Yeah, you don't want to let perfect be the enemy of good when it comes to initiating this type of thing. How high does the box work? Can you steps? So I think a box is superior. What you want to be able to do is work up to a height such that when the foot is on the box, the front leg is on the box, the thigh is parallel to the ground. So for most people that's 16 inches, maybe 18 inches, a very tall person might be 20 inches. I recommend people start at a 12 inch step until they, you know, sort of, and you start with your bodyway. Let's be clear. I mean, for many people just doing a proper step-up and step down with bodyway at 12 inches is right. And actually, in the book, it was becoming so difficult to write about this in detail that I did. There's a whole section where I write about how to do this. But in the end, we created a thing on our website where I just have a bunch of videos where I illustrate these things. So in the book, it directs people to where to go to just see, I think eight or nine videos of the most important exercises that I think people should be able to do. Well, we should put that in the video description. So we'll have to remember to do that. Yeah. All right. Let's, let's say, if you don't mind to nutrition and diet, and we can talk about obesity, diabetes, and inflammation on that front. I was interested in your comments on diabetes. So my understanding, and this is entangled with the problem of obesity, by understanding is that when physicians test for blood sugar, they age adjust the norms. And that strikes me as, let's say, peculiar because it seems self-evident that if you have normal levels of blood sugar at 40, but that would make you diabetic or prediabetic at 20, then you're actually diabetic or prediabetic. And what that implies is that the rate of diabetes, which is already ridiculously and preposterously, devastatingly high, is actually much higher than we think. So correct me if I'm wrong or elaborate on that. If you would, if you think I'm onto something there. So we don't do that. I can't speak to what any other physician does, but in our practice, we hold everybody to the same standard. I think we will acknowledge on one metric because we use a standardized dose of glucose. When we do what's called an oral glucose tolerance test, we will give women a little bit more latitude because they don't have as much muscle mass. So there's a particular test that we do where we give people 75 grams of glucose. And we time at 30, 60, 90, on 120 minutes what their glucose and insulin level is. And in that window of time, what you are testing is how efficiently do their muscles take up glucose. That's called glucose disposal. So you're measuring insulin sensitivity and glucose disposal. And in that window of time, that's the only place you can put the excess glucose. And because women have less muscle than men, we will tolerate a slightly higher glucose response, but we want the same insulin response. So that's, and it's a very subtle difference. But no, we don't age adjust for anybody. We sort of, we want a 60 year old to be as effective at this as a 30 year old. So can you outline for people what happens during normal Western aging, let's say on insulin and glucose metabolism front and what that implies for age-related degenerative diseases? It's a very interesting thing and we're not entirely clear why, but there is an unmistakable decline in insulin sensitivity as a person ages. Now, it doesn't mean that you're destined to have insulin resistance or fatty liver disease or type 2 diabetes when you age. But what it generally means is on average, a person needs to be more diligent as they age. And I've heard lots of theories offered for this and my guess is they all play a role. There's clearly a reduction in testosterone as we age. Testosterone is a very pro metabolic health hormone, right? So testosterone promotes lipolysis of fat by muscle. It promotes insulin sensitivity. In fact, there was a clinical trial about a year and a half ago that looked at men without type 2 diabetes, but who were pre-diabetic on and off testosterone replacement therapy. And you showed a significant reduction in the progression to type 2 diabetes in men on testosterone. So clearly the decline of testosterone is playing a role in both men and women, by the way. We also see less expression or less activity of an enzyme called Lypa protein lipase, LPL, where it shifts more of its activity from muscle to fat. This is again an enzyme that is responsible for the breakdown of fat. There are also other things, as you pointed out, such as inflammation that increases with aging. We also tend to be less active as we age. And one of the most important things to preserve insulin sensitivity is activity. So there's a really famous researcher at Yale named Jerry Schulman, who is one of the world's authorities on the ideology of insulin resistance. And when he does clinical trials, when he does experiments on human subjects at Yale, and he wants to study insulin resistance, the one criteria he must have is that the subjects can't be physically active. So in other words, for him to figure out what insulin resistance looks like even in a 20-year-old, he has to ensure that they are not exercising at all. So it's some combination of these things, and probably some other things that are explaining why all of us have to work harder as we age to avoid this phenotype. So maybe you could define insulin resistance, describe its relationship to elevated blood sugar, or to blood sugar in general, and then discuss the relationship between elevated blood sugar, insulin resistance, and aging as such. So think of the muscle maybe as a balloon, and the balloon is the only place where you can put air, and this analogy air is the glucose. So there are some balloons that are very easy to blow up, and you know, you can put the glucose into the muscle cell, you can put the air into the balloon quite easily. You don't have to blow very hard. But imagine a balloon that's very, very difficult to put air into. And at some point you can get air into it, but you have to blow much harder. So how hard you have to blow is the amount of insulin you need to put the glucose into the muscle. At some point you will not be able to do that. You can't blow hard enough. So again, just thinking about this in terms of physiology, glucose is a molecule that needs to be regulated very carefully in our bodies. Too much and too little is catastrophic. And so the body does a great job of trying to take excess glucose out of the circulation and put it into muscle cells. By the way, just to put this in context, Jordan, a healthy person has about one teaspoon of glucose floating around all of their circulation at any moment in time. A person with one teaspoon, one teaspoon, a person with frank diabetes has two teaspoons. That's the difference between healthy and nearly dying, right? It's profound. How many teaspoons of sugar are in a bottle of Coke? It's 30, I think, or 35. About eight. About eight teaspoons in a small, I guess I was thinking of a big, yeah, I was thinking of a big two-liter, and a big two-liter would probably be about that. Yeah. Right. So our body is amazing at doing this, but it's a very delicate dance between how much insulin do you need to make that happen? And the the the canary and the coal mine of insulin resistance is after a person is challenged with glucose, even if their glucose levels normalize, they needed supernormal levels of insulin to do it. That's the initial blowing too hard on the balloon. So when you develop insulin resistance, and that progresses to diabetes, you literally can't produce enough insulin to get sugar into the muscles. That's correct. Eventually, you cannot make enough insulin. And this is complicated by another factor, which ties into this cascade of metabolic disease, which is eventually fat starts spilling out from the cells that we are meant to use to store excess energy, which are actual subcutaneous fat cells. And that fat starts spilling into other areas where we're not supposed to have it into the muscle, which is what's causing the actual mechanism of insulin resistance. It's the fat in the muscle that is preventing the insulin signal from being heard effectively by the muscle cell. It also expands into the liver. That's what's called fatty liver disease, or non-alcoholic fatty liver disease. The fat starts to be deposited in the pancreas where insulin is made. And that creates an inflammatory environment to the insulin producing cells. So now you have the double whammy. You need more insulin, but you can make less of it because of the inflammation. And this thing very quickly spirals out of control. And the end state is type two diabetes. So now you have two teaspoons of sugar in your blood instead of one teaspoon. And so what are the consequences of that excess sugar load, which in absolute amount seems very trivial, right? I mean, one teaspoon in all of your blood seems like almost nothing. And two doesn't seem like much either. But the difference is at two teaspoons, the difference is starting to tip you towards, towards what sort of thing. So you have two problems going on now. You have too much glucose and too much insulin. Because remember, when you have that high level of glucose, you're going to be treated with drugs that aim to increase insulin. And that can sometimes be insulin itself, or it could be drugs that produce more insulin. So let's start with the glucose side of the equation. The easiest way I think to think about this is too much glucose is bad for small blood vessels. Too much insulin is bad for large blood vessels. So what are those small blood vessels? The very first place this shows up is looking right into the eye. So I've always believed that a good ophthalmologist will spot metabolic disease before any doctor will. Because when they can look into the retinal artery and see the earliest indication of microvascular occlusion and inflammation, that is tied directly to what's called the glycosylation. So glucose sticking to proteins, including hemoglobin in the blood, that's basically creating micro-scopic what we call ischemia or lack of blood flow to the most distal perfused organs. So other small vessels that are absolutely ravaged by glucose are the kidneys. So diabetes, along with hypertension, would be the most common driver of end-stage kidney disease. You also see it in the coronary arteries. Believe it or not, it's probably one of the most important physiologic drivers of a rectile dysfunction. Again, very small blood vessels in the penis. And therefore, when these things succumb to this type of end-stage glycosylation, you're going to see damage all around. Conversely, on the insulin side, elevated levels of insulin chronically, it's a pro-growth factor. So it's very likely the explanation for why obesity is the second leading environmental contributor to cancer after smoking. And it also damages large and medium-sized blood vessels, like the aorta, the carotid arteries, etc. So this cascade of, again, it doesn't sound like much of a difference, as you said. It's a chronic issue that over enough time leads to the destruction of most issues. So can you lay out the relationship now between insulin resistance, excess blood sugar, and the propagation of fat tissue? Now the fat is being used to store energy, but how does that actually occur? And how is that related to excess sugar? In many ways, we were doing really well as a species until 100 years ago, right? In that what allowed us to have this remarkable escape from all other species, vis-a-vis natural selection, was this ability to store energy and fuel our brains? So as we talked about earlier, like the brain is such an energy demanding organ that we couldn't have survived if we didn't have a way to keep energy portable with us. How would we survive a day with no food if we didn't have a way to store energy? Because certainly more than one day you have to use fat stores to get by. You can't just rely on glucose stores. So we have this very efficient way to do it. We have a very safe depot of subcutaneous fat where we can put fat in it, which is excess energy, and that's primarily fatty acids, and also excess glucose can be stored in this form. And we can acquire it as we need it, right? So, you know, when energy stores are low, you go and you get that, or when energy itself is low, you go and acquire this. The problem comes when you exceed the capacity of that. So the way I describe it in the book is everybody, and this is largely determined genetically, everybody has a bathtub. Some people have a really big bathtub. Some people have a really little bathtub. The bathtub is the total capacity of your fat, your fat cells to store fat. So water goes into the fat cell. That's the food you're eating. There's a little drain at the bottom, which is all the energy you're expending. That's coming out. And therefore, the energy in less the energy out determines the balance of water in the tub. If you're getting fatter, the water is rising in the bathtub. At some point, the water gets to the lip of the tub. You have now exceeded your capacity for safe storage of fat, or in this case, safe storage of water. What happens next is the water spills over. Now it's gone from being totally physiologically normal to total chaos. Just as if water spilled over your bathtub, it would be total chaos, right? It would ruin your house. And the question is, where does that fat go once it spills over? And it's where it goes that causes all of the problems we're talking about. When it goes into the muscle, it impairs the muscle's ability to sense insulin and create the glucose transportor to bring in glucose. That's the sincwanan of insulin resistance. When it goes into the liver, it creates inflammation, which can ultimately lead to cirrhosis and liver failure. When it goes into the pancreas, it secretes cytokines that impair the beta cells, which produce insulin, which exacerbates the insulin resistance problem. When it surrounds your organs as what we call visceral fat, it releases inflammatory cytokines that lead to cardiovascular disease disproportionately. So again, all of these things are happening, not because we're getting fatter in the right place, i.e. water in the bathtub, but because we're getting fatter in the wrong place. And this is another example of which it doesn't take a lot of fat to spill over. If a person has 20 kilograms of fat in their fat cells, it causes no issue. It's the two kilos that have spilled out into all those other organs that are driving all the damage. Yeah, and I read too. This is another example of the dangers and sometimes benefits of the things that you repeat every day. I read at some point a while back that the obesity epidemic, such as it is, could be regarded as being caused by the additional consumption of one soft drink a day, non-diet soft drink, obviously. Because, of course, there's a lot of sugar, eight teaspoons, which is four times as much as you have in your blood if you're diabetic, but you're doing it every day. Now, and so that is hard on the systems that use insulin to process sugar, but it also puts this demand on your body to deal with the excess glucose. How is that glucose converted to or stored in fat? What's that mechanism? So, it's called the technical name is is is a denovo like pogenesis, like pogenesis, making fat denovo from scratch. So, the liver can turn, the liver is a amazing organ, by the way. It's just if we're going to give a shout out to any organ in the body, it might have to be the liver. It's just an unsung hero. It doesn't get the attention deserves to put just to go back to one other thing. This whole teaspoon of glucose in your bloodstream, if that number gets to half a teaspoon, you'll die. Your brain won't have enough glucose. But yet, you're churning through that at a rate of a teaspoon every couple of minutes. What's responsible for that titration? The liver. Never stops. So, one of the other things that the liver does miraculously is it has the ability to turn fat into glucose. It has, pardon me, it has the ability to turn glucose into fat, and it has the ability to turn protein into glucose. So, it can also change the orientation of molecules. And so, the process of turning glucose into fat is basically an exercise in breaking glucose, which is a six-carbon molecule down into two-carbon chunks, and then joining them in a long fatty acid chain. We would much rather store energy in fat. It's the most efficient chemical molecule in which to store energy. All the energy, of course, in our body, is in the form of chemical energy. Stored in the bonds, carbon to carbon and carbon to hydrogen. And a fat is the most efficient vehicle to do that. So, we would much rather actually store energy as fat than in glucose. And we don't store that much as glucose. Okay. So, let me step sideways here for a moment. I'd like to talk about the food pyramid with you. And so, I'm going to lay a little bit out about my understanding of the food pyramid and how it came about. And then we could talk about the standard Western diet and its relationship to insulin resistance and obesity. So, my understanding is that the food pyramid was actually produced by not by scientists or by MDs, although there were some MDs who were consulting, who were mostly ignored, but by the department of agriculture. And it was a marketing scheme, essentially. And that the consequence of the marketing scheme was that people were enticed and convinced to rely primarily on carbohydrates for their nutritional necessities. And perhaps carbohydrates at far too excess at level. Now, carbohydrates are transmuted into glucose during metabolism. And we eat way more carbohydrates that we need to produce the amount of glucose that we need. Now, people have been getting fatter in a catastrophic way for about four or five decades. And that's really in no small part since the introduction of the food pyramid. Now, I do understand that part of the reason the department of agriculture did this was because carbohydrates, and this was particularly true of corn syrup, do provide a very inexpensive source of calories. And if you're dirt poor and you don't have enough to eat, I mean, just getting enough calories period is a vital importance. Not everybody can afford steak, for example, or more expensive foods of that type, but virtually everyone poor and not in the West can afford basic carbohydrates. But now we're in this, but having said that, I also have read and I think it's valid that there was early evidence that this heavy carbohydrate loaded diet that was being prescribed was going to increase obesity and diabetes, which is done at a level that makes the pandemic epidemic look like absolutely nothing. And this is still being pushed forward by people who are hypothetically on the nutritional front. So two questions. What's your understanding of the derivation of the food pyramid? And what do you think about its recommendations for the typical diet? So I think before getting to that, there's a broader point I want to touch on that you just sort of alluded to, which is what is the system optimizing for? So in the book I talk about the standard American diet, which I forever abbreviate as the sad. And the standard American diet is effectively with or without food pyramid. The standard American diet is what is killing people. And so the question is where did the standard American diet come from? The standard American diet was nothing more than the solution to a business problem. So the business problem was we need something where we can produce lots of food. So you had to have this quantity issue, right? So that gets to part of the problem, right? We have too many people at the time who are undernourished, we can't have that anymore. Everyone needs to be adequately nourished. So we need scale. The next thing is exactly your point. It can't cost too much. So we have to be able to do it at scale and it has to be cheap. The third question or problem statement was it has to be non-parascible and portable, right? So you can't have abundant food if it needs to be consumed 10 minutes after it's made. So it has to be sort of non-parascible. The third, sorry, the fourth and final parameter, I guess, there would be it has to taste really good. We have to make food very palatable. This, again, it's just part of a business and marketing strategy. And what I argue, I guess, is that the solution to those four things is what we have today. Like when you walk through a grocery store, all you're looking at is the solution space to a problem statement called those four questions, and it's called the standard American diet. Now, whether without a pyramid, I'm going to just argue that 95% of people, if they go through life eating the standard American diet with no attention to how much of it they eat or maybe certain things in it that they shouldn't eat, are going to be unhealthy. There just aren't that many people that have the genes to avoid the deleterious consequences of the standard American diet left unchecked. And therefore, what, yeah. Well, so that was the least conspiratorial account of the origin of the American. Well, I mean, I've heard and that's fine. That's perfectly appropriate. I mean, I do think that we could give the devil as do and say the consequences that we have today of this epidemic of obesity was in fact the consequence of solving a problem too effectively. I mean, the middle of supermarkets, the outside edges of supermarkets don't contain generally highly processed carbohydrates, let's say, but the center does and they are cheap and they are delicious and they are easily provided and they are portable and they aren't and so that did solve the problem of under nutrition on the pure caloric front. So we're victims of our own success in that sense. And I suppose it's perfectly reasonable to dispense with the accusations that the food pyramid was nothing but a marketing scheme because it did have to solve these four problems that you described and did so. Yeah, I mean, I think what I certainly don't want to give the food industry a pass. I mean, we can certainly delve into that, which is to say there's no question that data have been suppressed, right? There's no question that we're not having an honest discussion about the following. So are all calories created equal from an energy balance standpoint? Sure. At an isocaloric level, if I give you a thousand calories of Coca-Cola versus a thousand calories of baked potatoes versus a thousand calories of steak, it will have the same impact on your energy balance. But it won't have the same impact on your appetite and your ability to subsequently eat. I mean, to me, that's the most, I think, probably offensive aspect of where the food industry has failed. Right? So the food industry didn't set out to kill people any more than the tobacco industry did. Where these people are effectively liable is in that they're not honest about the discussion until, you know, it becomes too late. And the reality of it is junk food, I think hijacks your normal appetite centers. And I know people who are very good at working within those confines. So I know people who can eat junk food in small amounts and continue to eat nutritious food and stay in overall energy balance. They can track their calories perfectly and they can have a couple of Oreos and some ice cream here and there and drink your soda here and there and they're all fine. What I can just tell you clinically taking care of actual people who are not robots. On average, more people than not struggle with that. And with the introduction of these very hyper palatable foods that kind of hijack your appetite, it tends to produce overeating. And ultimately, that's the problem at hand here. When people overeat from whichever part of the pyramid they're going to overeat from, we're going to get down that whole cascade we just spoke about. It just so happens that I think the things at the bottom of the pyramid are the things that are making it easier for you to be disconnected from the true driver of appetite. And there are lots of hypotheses here, right? There are some hypotheses that we are kind of hardwired to get a certain amount of nutrient value. And as the nutrient value of our food deteriorates, we have to eat more food. We have to eat more calories to get the certain nutrient density. There are people who argue we're hardwired to get a certain amount of protein. And as we're deluding protein content in food, we're eating more calories to get food. In other words, and by the way, I don't think any one of these particularly is necessarily the explanation. My guess is it could be a lot of the above, but it's probably the case that we are opportunistic omnivores. We grew up, we evolved, eating pretty much anything we could, but we didn't eat that much of it because we didn't really have that much of it and we were wildly active. When you eliminate those two consequences, being opportunistic omnivores is not working for most of us. We have to be more selective to push back against the amazing success of our civilization. Yeah, well, it is a remarkable thing that you can walk into your local Starbucks and there's one on every corner and get an 850 calorie muffin for essentially nothing and that it is delicious and that it is addictive and it is a hallmark of a certain kind of success. I'm going to go sideways here for a minute because I have something I suppose that's slightly more on the personal side to ask you about. As you may or may not know, my daughter was very ill with a plethora of immunological problems, including very serious juvenile arthritis. It just about killed her. It did destroy two of her joints and she had another 38 that were affected and so she was always in a lot of pain. I looked into the role the diet played in arthritis through the scientific literature for a couple of years and found two things and they were somewhat contradictory and one was that there was no real evidence that any specific elements of diet had been linked to juvenile arthritis specifically, but and this was a major but if people who are arthritic fasted completely, then there are three different symptoms often disappeared. So I thought that had something to do with the consequences of fasting but then my daughter started to play and my wife as well, very intensely with the diet, we went to a nutritionist who recommended elimination diet at one point because she did notice that she would react to strawberries and oranges. We could and within a day her thumbs would swell or her toes would swell. We knew there was some thing she was eating. We had her tested for immunological reaction to food but when we tested her, she showed a hyper reaction to virtually everything they tested her for and we concluded at that point, well there's no damn way she could be reacting to everything she's eating. Well she went on this elimination diet and showed a bit of reduction in symptom but the elimination diet made no sense. Like there was no rhyme or reason to what you could eat and what you couldn't eat and so she started to experiment with more restricted diets and eventually settled on discovered that if she only ate beef and it turns out for her, it has to be beef that isn't aged, then all of her immunological symptoms disappeared and then my wife and I started playing with that diet and so I've only been eating meat for beef fundamentally for almost five years now and I've talked to hundreds of people and we've had messages from thousands of people showing that this is first of all radically effective as a weight loss strategy and also seems to produce remarkable effects on the general disease symptom front. Back in November of 2021, there was a study published by a Harvard group which wasn't a perfect study because it was retrospective self-report but they followed 20, they assessed 24, 25, 100 people who had been on a carnivore diet for six months and showed something approximating a 90% reduction in all disease symptoms and it was the only scientific paper I ever read where the surprise of the researchers was palpable between the lines in the scientific writing because you know in a scientific article all that emotion negative or positive is pretty much ironed out but these people were so shocked by what they found that it couldn't help leaking into the document and so while this has been quite surprising to me because I never imagined in my wildest dreams number one that you could just live on meat number and number two that it would have such a salutary effect. So for me, I lost 52 pounds in seven months. I went from 212 pounds to 165 which is exactly what I weighed when I was 23 and I've maintained that weight since. I can put on muscle mass with no problem even though I'm 62. I had a host of inflammatory conditions some of which were quite serious including peripheral UVitis which sometimes blinds people in my right eye and it disappeared completely along with psoriasis and gastric reflux disorder and interestingly enough gum disease which is technically incurable which is linked to cardiovascular degeneration and which has gone away 100% in my case according to multiple measures that my dentists have taken and so when I've talked to many people who've lost like a hundred pounds in a year you know because they come to my talks and who are just beside themselves so to speak as a consequence of experimenting with this diet so well so that's the story. It's very strange. I don't talk about that much because I'm not a nutritionist because I'm still shell-shocked by it but I'll tell you it's something to be 60 and to have the same essential body morphology that I had when I was 23 and that had all disappeared for me in my early 50s. Yeah you're not the first person I've heard this story from Jordan and I have to be honest with you. I just don't know how to explain it. The weight loss by the way is not the harder part to explain right so the more restrictive any diet is the more one loses weight on average right so I wouldn't surprise me if we put a person on the all potato diet if they would lose weight whereas if you put somebody on the no lettuce diet nobody's going to lose an ounce so more restrictive diets ketogenic diets which are not as restrictive as what you're doing are also very effective for weight loss. By the way so is a zero fat diet. Now it's an unpalatable diet and I don't think it's particularly healthy diet when you sort of start restricting fat that much. The more interesting question to me is you know and I can certainly understand if you would say I have no desire to experiment further by introducing other elements to see if I can preserve this phenotype but the most interesting question to me is what are the other foods out there that you might be able to consume or in the case of your daughter right like is it I'm obviously interested in that too but I what I have found because I have now and then tried to eat carbohydrates what I have found is that if I eat any of them I start to crave them intensely if I don't eat them at all I they don't bother me assuming and this goes to the calorie restriction issue. One of the ways of maintaining yourself on a keto diet or a carnivore diet let's say is to make sure you're never hungry and I eat a lot of meat and a lot of high fat meat and so I'm never hungry and I don't think that I'm calorie restricted at all because you know I can eat all a tomahawk steak sometimes in one sitting which is about 35 ounces of meat I never get hungry and I eat high fat carnivore snacks too. What I found is as long as I'm never hungry then I I'm not inclined to cheat but if I do try something like an introduction of carbohydrates first of all some of my symptoms come back right away like the girds and I start craving like mad so well so that's why is it is it is it all carbohydrates or like for example if you introduce vegetables non-starchy vegetables what happens both symptom wise and craving wise. Yeah well for a while I was eating nothing but meat in greens but I still had some residual symptoms my wife has a host of immunological problems that are somewhat low level and I have a different host and Michaela seemed to get all of them and so you know maybe we're absurdly sensitive for reasons that wouldn't be true of other people but it's definitely the case that I do better and believe me this isn't something I particularly want it is the case that I do better if I just stick to beef now could I have pork and chicken I had a very terrible boat of ill health and I'm disinclined to do a lot of experimentation although I'll probably try again in the future sometime but I do know that beef works we've been hypothesizing internally in our family for what it's worth is that the reason that beef works and that other rumoured animals bison so forth lamb goat is because they process what the eat through so many stomachs that by the time it is actually turned into meat there's pretty much nothing else there so it's it's a very purified form of nutritional very well very purified form of food now like I said that's anecdotal and this is partly why I don't talk about it but I can tell you after you've talked to a thousand people who tell you the same anecdote you don't have an anecdote anymore you have a hypothesis and it's really quite something seeing these people who show me pictures of what they looked like a year ago and you know they were carrying around an extra person with them and they're still shell shocked by the transformation you know because it's really something to lose say 150 pounds in a year and so well I don't know what to make of that I do know that it's been the diet has actually been rejuvenating for my wife and I like it's effect on muscle tone has to be seen to be believed and that's true even though both of us are 60 like my wife is in better shape from a musculature perspective now at 63 then she was when she was 40 and she was a very physically fit person who was exercising constantly and who was in pretty damn good shape and to see that reverse rather than just you know stop deteriorating I don't really know what to make of it I would love it to be studied prospectively I'm very curious as to what's going on in particular with with that I mean there are lots of data out there showing the efficacy of a ketogenic diet in the amelioration of type 2 diabetes I do think I mean look when it comes to type 2 diabetes any amount of weight loss is going to produce a benefit but it seems that a ketogenic diet has the easiest compliance and there might be something to the fact that it's kind of removing the thing of which there is an excess right by by at least taking away the thing that is in most excess it's easier to kickstart that a fast of course is also a great way to kickstart that right something about taking a what taking glycogen levels down in the liver and the muscle makes this easier well that the advantage to of the diet the carnivore diet particular is because you can eat as much as you want it's actually not a diet you know the problem with diets is that they require privation and they require almost continual privation and then they also tend to produce a yo-yo effect and that's partly because if you get in a fight with your hypothalamus which drives hunger you're going to lose because it's there to make damn sure you don't starve and the probability that you can overwrite it for any length of time well it's very very low and that probably varies from person to person for all sorts of reasons but you don't want to get in a scrap with your lower level motivational systems now you know if I ever start to crave a banana split for example I can just eat another five or six ounces of steak and then I don't care it's not like it wouldn't taste good you know but it doesn't preoccupy me the way it would if I was hungry I've really noticed this when I go into grocery stores because if I go into a grocery store after having consumed enough meat then the provision of this infinite display of delicious foods really doesn't affect me much but boy if I ever go into a grocery store when I'm hungry that's quite the pain in the neck because everything's delightful and tempting you know so the fact that you can eat enough or even as much as you want on a keto or carnivore diet does seem to distinguish it in some ways from the diets that depend more particularly on mere calorie restriction although I've seen the subset of people on ketogenic diets who gain weight so they somehow are eating past their necessary their their their their energy point I was on a ketogenic diet for three years actually I used to write about that's in fact when I started blogging in 2010 2011 it was basically to I was mostly talking about nutrition and for three years minus one day of my wife's birthday one one day in that three years I had seven pieces of dessert but minus that one day I was in a state of ketosis for three years and yeah in many ways I was the poster child for it like it the the efficacy in me was out of this world um what did it do for you oh I mean I lost 40 pounds I you know was probable I mean just from a body composition standpoint was you know by Dexa which is the gold standard about seven and a half percent body fat every metric of every biomarker you could measure or possibly care about was in the you know even by my standards which are not to consider what's optimal but to consider what's exceptional everything was great even things that historically people think you can't do on a ketogenic diet like lots of intense exercise certainly initially I couldn't do much of that but within about six months I had regained much of my exercise ability and by 18 months I had certainly no discernible reduction in extreme exercise performance again I don't have a counterfactual you could argue that that's still lesser than what it would have been at an apenetic ketogenic but you know some people sometimes say well Peter why aren't you on the ketogenic diet anymore why did you stop in 2014 it largely came down to I think just not wanting to be restrictive anymore and wanting to kind of you know as my at the time daughter was getting a little bit older it was you know sort of wanting to enjoy more of the foods that I was was limiting but the reality of it is like I don't you know I'm certainly not as lean as I was when I was on that diet yeah yeah yeah well the other thing I noticed this is also very cool and it's very important to me personally so I noticed that as I got older my ability to concentrate when I was reading was deteriorating so when I was 25, 30 when if I picked up a book and read it I would shut everything else out and I would remember concentrate on focus on attend to what I was reading read every word and understand it with no problem but that started to deteriorate as I got older and I noticed that it took an increasing amount of effort to shut everything off and that instead of reading as deeply as I was I was sort of glancing at the words and when I started this carnivore diet that reversed and I can now I think I actually think this is true I think I can read faster and more efficiently than I could when I was in my 20s and I was pretty good at it when I was in my 20s and so the other thing that I've known as too is that I don't have periods of time this was quite a problem for me and it might have had something to do with my immunological problems is that I would get hypoglycemic and lose the ability to concentrate and get what do they call it hangry you know hungry and angry and irritable and that would happen several times a day probably because I was working too much but in any case that is gone completely and I really don't miss it you know I wake up in the morning with a stable mood and my mood doesn't very much throughout the day I'm also much more stress tolerant and able to rebound back from stressors faster and in terms of endurance you know there were lots of times over the last three years when I was walking nine to 12 miles a day on a carnivore diet I wasn't running you know but my experience is that I'm stronger and I have more stamina than I did 10 years ago and that's quite something given that I'm now 62 that's a good direction you know it's one thing like I said it's one thing to halt the aging process but it's another thing entirely to see it start to reverse and so you know we don't know anything about a street carnivore diet to very little and no one has done a prospective study it's one that I'm actually thinking about setting up funding for if I can find researchers who are interested because there's something there and it was certainly established by that initial study at Harvard so if you know anyone who's interested in doing that you could always hook them up with me sure I some folks there are some folks to come to mind actually okay okay all right so do you want to talk a little bit about the other more common diseases that you deal with in the book you talk about heart disease we've touched on heart disease you talk about cancer neurological degeneration Alzheimer's for example let's walk through that domain a little bit if that would be okay with you sure we're just like to start let's start with cancer everyone's favorite yeah I think you know cancer is the second leading cause of death in in the United States and globally of the what I describe as these four horsemen of death cardiovascular disease cancer neurodegenerative disease and the metabolic diseases that we've already talked about cancer hits its peak first so the other diseases rise monotonically with aging cancer actually peaks in late middle age so so cancer would be the leading cause of chronic death or chronic you know chronic diseases of aging in the 40s and 50s and 60s before it's supplanted by cardiovascular disease and even neurodegenerative disease if you go back to the year I was born and you asked the question what is the probability that a person with metastatic cancer i.e. cancer that has spread from its primary organ to a distant organ what's the probability they're going to be alive in 10 years the answer was 0 percent nobody was going to survive that today the answer is about 5 percent maybe a little bit higher but it's it's really not been an enormous source of success so let's talk about what the bright spots are the bright spots are leukemias lymphomas testicular cancer these are areas where there has been great progress and your survival today is so much higher than it was 50 years ago when you talk about the big killers though which are lung cancer prostate cancer breast cancer colon cancer pancreatic cancer those are the top five causes of cancer death median survival the length of time you survive has increased by as much as a year if not more but overall survival has not this is a very important thing to understand the risk of being dead in 10 years if that cancer has spread is the same as it was 50 years ago so if all that's the bad news do you suppose that's a possible consequence of the presence of cancer being a marker for like cumulative systemic failure is that it's if there's cancer somewhere is it an indicator that many things have gone wrong at many levels and so even if you treat the cancer the probability that that's going to be life saving is quite low or is it just a consequence of the tremendous capacity of metastatic cancers to spread so there's a couple of things going on for cancer to take place so so if the first critical step of a cancer is a genetic mutation has to happen and largely speaking these fall into two categories there are genes that are promoting cancer growth and then there are genes that suppress cancer growth so anytime you get mutations in one of those systems it becomes oncogenic now fortunately when a cell becomes cancerous it starts to let out clues that it is not a normal cell so when a breast cell goes from being a normal mammary cell to a cancerous mammary cell it starts to look a little bit different and the immune system our immune system the cellular immune system is very good at patrolling the body for signs of things that are not self that's what it's programmed to do so the it's a very beautiful way to think about it but the immune system is not programmed to recognize bad things it's preck it's programmed to recognize things that are not self this is done through something called phymex selection when we're you know basically very young so and by the way too much of that problem leads to autoimmunity so that you know you can think about this through your own personal story right which is there's a very fine balance here too much of knowing what is you know not self and too little of that are both equally bad so there are always some cells that recognize this in fact Steve Rosenberg who I did my post-doc with recently published some really amazing data which I find one of the most staggering statistics of all of cancer and also one of the most hopeful which is that 80% of epithelial tumors epithelial tumors are the ones that kill people that's the solid organ stuff the breast colon prostate etc 80% of those tumors produce what are called novel neoantigens meaning they produce peptides small proteins that are not self and are recognized by the immune system as not self the problem is the reason those 80% of patients don't go into spontaneous remission is they can't mount a strong enough immune response to that so it's sort of like having some immune cells that recognize you have a virus but not enough that they can actually kill the virus and ultimately the virus kills them to your broader question which is if you're listening to this what do you do about it it starts to me with what are the two most clear environmental triggers of cancer and how do you avoid them and then secondly what's the rest of your strategy so when it comes to heart disease and neurodegenerative disease and metabolic disease which are the other three horsemen our ability to incorporate prevention is so significant that it plays the lion's share of our strategy because we have such an understanding of the risk factors for Alzheimer's disease the risk factors for metabolic disease and the risk factors for heart disease your prevention strategy is not doing those 25 things or minimizing how much you're doing those things with cancer there's really just two big things smoking and obesity slash insulin resistance now the literature would just say obesity but I add insulin resistance because I think that the literature is too blunt a tool to tease out what's really going on and what's really driving it I think is the inflammatory and metabolic i.e. the high growth factors such as insulin that are coming with most but not all cases of obesity so what we really want to avoid is being metabolically unhealthy and smoking but here's the thing so that insulin insulin overproduction also in your opinion facilitates cancer origination or or or or or or propagation cancer has I don't think I yeah I think it's a propagation issue not an initiation yeah yeah right and we know that because there are more than 20 cancers whose risk for whom your risk goes up by about a 2x factor if you're obese and I think the only thing that makes sense in that sense in understanding that observation is the inflammatory and pro-growth environment that is in that individual so do we want to avoid that absolutely but but my point is there are think of how many people who are non-smokers who are metabolically healthy who still get cancer that's a very long list of people so I wouldn't be able to hang my hat on this as well my anti-cancer strategy is not smoking and being metabolically healthy and hoping that that's enough we have to have another tool in this toolkit and that tool is a very controversial one but nevertheless I think it's important and it's very aggressive screening and the reason for this is another observation that I don't think gets enough attention which is when you consider two different individuals with the same cancer but at different stages who are treated with the exact same treatment their survival are very different so if you take a person with stage 4 colon cancer which means the cancer has spread to say the liver and you treat them with the same cocktail of drugs that you give a person at stage 3 cancer where it's just spread from the colon to the lymph nodes but no further at least to the naked eye the survival for the people for whom it's spread to the liver is 0% at 10 years whereas the ones to the lymph nodes it's going to be about 60 to 65% at the same period of time a fundamental difference they're getting the same treatment so it's the difference between treating somebody when they have a billion cells versus a hundred billion or a trillion cells and the problem is that there's more mutational burden the more cancer you have you have more escape mechanisms for the cancer that's probably the best explanation for it all of the and we could do this analysis for all other types of cancer like breast cancer etc what it points to is early detection is essential so what does that mean practically what what do people have to do with their physicians in order to ensure that they're being optimally screened for for the possibility of cancer and at what age does that start to become more crucial it's very difficult for me to provide a blanket statement because even when I'm talking about this with my patients I have a long discussion with them about the challenges of doing this so let's put aside the obvious challenge which is cost none of the advanced types of screening or working at the advanced rate are going to be covered by insurance right so in the United States it's recently been changed to 45 from 50 for the initial colonoscopy that's an excellent step in the right direction I still think it's about five years too late I think even for a person without a family history of colon cancer I would recommend and at least for our patients would recommend screening at to begin at 40 instead of 45 the frequency with which it's not cheaper it's not cheaper for the insurance companies to screen and it is to pay for advanced cancer treatment in hopeless cases oh it certainly is but you're you're confounding something which is at least in the Canadian health care system that might make more sense because the government owns the risk for life so at least if I don't and I can't you know despite the fact that I grew up in Toronto I can't really speak to the Canadian health care system with any authority but at least that's something Canada has going for it which is when you're 40 getting a colonoscopy or when you're 50 getting a colonoscopy that catches a little polyp that costs nothing to remove and prevent it from going to cancer you still own that life and that risk 10 years later in the US that's not the case in the US people are never really owned from a risk perspective by one entity for very long so there is much much less incentive in our system unfortunately to truly invest in prevention and that's a you know if we were to talk about the structural problems of the US health care system that might be the single most important one well the other problem on the prevention front you know is that prevention isn't dramatic because you get no credit for preventing a hundred things that don't happen you know if you cure something that's pretty dramatic because someone's ill and you cure them and the fact that they're no longer ill as self-evident but if you stop something cold in its tracks all that happens is that people pay attention to other problems and other let's say more uh showy and noticeable cures and so it's not only hard to fund prevention it's also hard to market it right because you can't give credit to the people who've managed it and so that's a that's a big structural problem like it it seems one of the logical conclusions from our conversation was that it would have been a much better investment on the government side and on the social side to have put a fair chunk of the money that was spent on cancer treatment into prevention of the entire range of diseases that we've been discussing and with with primarily with the focus likely on what on obesity as the number one is it is it i think i think it's the number one concern across all these classes well clearly generative disease uh oh yes yes if you're going to say oh well it's metabolic disease right so obesity is just a proxy for that but yes metabolic disease would be the you know one that feeds and amplifies all the others um but there are other things that we haven't explored like i don't think we have done a decent job remotely of understanding going just going back to cancer what the impact is of other environmental toxins in cancer and the reason i think it's so important in cancer to look at this is because smoking and obesity only explains so much of it so in other words the i can't tell you what the number is but it's noable and it's large the number of people who get cancer who are neither smokers nor have obesity or insulin resistance and so there's still a big fraction of people for whom something else is driving their cancer and i suspect there are other environmental toxins whether they be pesticides whether they be you know chemicals in the grant like there are other things out there that might not produce a large enough signal to show up either because of their ubiquity or because the direct impact is not as large and the fact that we don't know this to me is problematic right so that's another variant in some ways of prevention to identify additional mutagenic agents we already know about that on that smoking front but and then to take them out of the environment so that diseases don't occur to begin with let's switch by the way i do i do want to i do want to say one thing about what you said Jordan that is very true and there's no disease for which it's more tragic than with the the demanding diseases specifically all simrous disease so if you want to look at the amount of research that's gone into treatment versus prevention it's in dollars spent you'd need scientific notation to tell you what that ratio is like it's 99.999 to 0.0000000 why it's not even close and the net result has been abysmal so there is no disease for which we have less to show for the work that's gone into it than all simrous disease right we have a couple of approved drugs go ahead yeah we have a couple of approved drugs that have virtually no efficacy at best they might slow the rate of progression zero reversal and yet i think it's crystal clear that your trajectory towards all simrous disease is probably much more malleable than your trajectory towards cancer and we should have a very clear playbook on what that looks like given how difficult it is to treat that disease once it's present right well i guess the other problem on the prevention front is that it's it's more difficult to monetize prevention it's quite straightforward to monetize drugs to cure or to not cure as long as they're administered to enough people but how do you monetize prevention and and people might say well everything can't be about money it's like well without money you can't market and without marketing you can't communicate and so there's all sorts of obstacles that are quite subtle in the way of mounting an effective prevention campaign and but it does it certainly seems if you let's let's close with two questions one might be if you could seize control of public health spending on the research and public policy front where would you devote the bulk of resources now i mean like one example might be well you know would we start a campaign to reduce the consumption of carbohydrate especially sugar but but but we talked about other elements of prevention as well if we're going to spend our money research money in our public health money efficiently and get the most bang for the buck where do you think we should spend it and what evidence do you have to support that it's really hard to say because this is just as much a behavioral question as it is a scientific or medical question again the numbers point back to exercise Jordan there's no ambiguity about that right you're going to get more benefit in a person's health if you get their VO2 max high you put lots of muscle mass on them and you create a high degree of strength and that's going to be true for men women young old it doesn't matter there is no exception to this rule and therefore um you know i would put most of my resources from a public health standpoint into how do you do that how do you make exercise something that is interwoven from preschool onward at a level that is truly efficacious and that's going to not just mean getting people to exercise it's going to be figuring out ways to change the environment that supports being active more often so that you're being active and not even when you're not exercising but it's also going to involve understanding that everybody's different there are some people who hate exercise and what do you need to do to make it more enjoyable for those people what kind of financial incentives do you put in place for people to exercise because i really do believe carrots can be more effective than sticks here and uh you know simply you know i mean we talk people are sitting here talking about you know universal basic income as a potential way to alleviate some of the societal problems well if we're going to be paying people maybe paying them to exercise um and providing you know a way for for a really good incentive around this because it's going to obviously save cost but i think more importantly improve the quality of a person's life no individual cares about the cost right because they're not bearing the cost so that's a the arguments around that i don't think matter i think the only thing that matters is can we have you do something that's going to improve the quality of your life wonder wonder what would happen if we took kids out for a 15 minute walk every morning as part of the school curriculum made that habitual you know it'd be good for the kids too because they might be able to sit down and attend a bit more if they actually had a bit exercise before they were required to sit and do nothing for six hours so you know to build to start building those habits of activity uh in youth so that they i mean i would get i would get rid of chairs i would get rid of chairs in schools every kid would have a standing desk i mean there's the sitting is just uh it's not a particularly productive thing in the position we do it in right i mean sitting in a squatted position is fine uh but this the angle that we're sitting at is really it's it's it's not conducive to the great biomechanics later in life so we you know if you watch a child your kids are probably too old now but mine or not i can see the change in body mechanics as they go through more and more time in chairs and it's true of adults well right well while you're obviously what we're doing in schools is training people to be sedentary yeah obviously i mean that might be the most fundamental impact of the education system you know i read an interesting book years ago called system antics by my name john gall and it's a set of aphorisms about how systems work you know and one of the aphorisms which i never forgot was the system does not do what its name says it does and so when you analyze a system for example one of the reasons i think that universities get away with charging tuition fees that are like absolutely unreasonable by any standard is that you have a pretty decent chance of meeting your lifetime mate if you go to university and so it might be that the fundamental function of universities is to aid in the process of the sort of to mate it like systems are very complex and hypothetically the education system educates kids but what but it's fundamental function for all we know might be turned to turn people into sedentary nobis adults because we don't know right we're not smart enough to analyze the behavior of these complex systems let's end with one final thing we touched briefly on the issue of emotional health and so tell me tell just tell me your thoughts on that in general what are your recommendations in outlive in your book and and how do you how do you associate the issue of psychological and emotional health with the well with exercise and diet for example or any of the other lifestyle modification processes that we've discussed so i think emotional health ties into this longevity equation in many ways so you can start at a very extreme end uh a low enough state of emotional health can be a direct threat to your life so again the most extreme extreme example of that would be suicide but if you walk back from suicide we talk about parasyuicide we talk about all the different behaviors that people engage in that are slow suicides i can't speak to what the statistics are in canada but in the united states and i suspect you know these more than i do jordan uh if if we look at three categories of deaths of despair suicide overdose and alcohol related death uh so cirrhosis things like that uh the deaths of despair have been increasing at anywhere from 10 to 20 percent year on year on year over the past four or five years so we just for that's brutal yeah so just last last year was the first year that overdose took more than a hundred thousand lives in the united states so yeah well you know it's an open question how many people on the edge of of depressive collapse were tipped over that edge by the lockdowns and the prolonged social isolation and the increase in fear you know up in Toronto i still see people and in l a2 it was quite noticeable i was there yesterday i still still see people cowering behind their masks and no you have to have been made pretty chronically afraid to still be doing that and the the uh cost to people's health of the fear campaign that drove that drove the lockdowns we're going to see that i mean i don't know how that's contributing to the excess deaths i think it would be very difficult to say that those statistics i rattled off aren't impacted by covid so what's going to be interesting right is to see how that plays out going forward my point of course is that these deaths of despair are a very extreme example of how emotional health impacts longevity directly right here it's just truncating lifespan way too soon in fact overdose is now the leading cause of death in the united states for people age 10 to 55 wow wow that's terrible so and so so what do you see on the prevention front there or do you have well let's go even one layer further because i'm sure there's someone listening to this who says well look that's not me i don't drink to excess i would never touch an illicit drug and i'm in no danger of killing myself so that that means emotional health is checked and i would say now not really because that's just the first layer let's go one layer deeper i think the next layer is how many people because of their relationship with themselves are unable to self-care if we're really going to be honest about it how often do we engage in not what would rise to the level of quote unquote harmful behavior but certainly things that are not in our best care eating a little bit too much not exercising enough not sleeping well you know engaging in behaviors or failing to engage in healthy behaviors now again i see this constantly with patience where it's not that they don't know what to do it's not that they don't know that they should exercise but if you really push them they have a negative relationship with themselves that is preventing them from taking care of themselves and i would say that the impact on on length of life there and quality of life is much bigger than the deaths of despair but it's much harder to quantify so then i'd go even one step further and say okay well you're not in category one where you're an immediate threat to your life because of this emotional your emotional health and you're not even at the point where you're failing to take care of yourself but now you maybe land where you're you're you're just unhappy your your your your relationships suck right you're you're a lousy father you're a lousy husband you're a lousy parent you know any of these things and you're basically living without a sense of why right you're you're you're not um you know as as sr. Porelle put it to me what is the purpose of living longer if you're unhappy and i think that that's probably the biggest circle and and that's to me one of the most interesting ones here and and again for me personally the the one i wanted to explore the most in myself which was how much of this obsession with longevity is about figuring out how to not die versus understanding how to live and so what what have you concluded on the treatment front in regards to to that set of problems or the prevention front let's say well again it's worth caveatting that everything that i write about in the book i come to it with some lens of expertise right i mean it's what i do for a living it's what i've spent more than a decade researching you know i can i can speak with some authority about cancer and heart disease and dementia and exercise and nutrition when it comes to this particular issue i have no expertise i come at this through the lens of a patient and therefore i think everything i say must be taken with the understanding that it's somewhat anecdotal um and therefore needs to be explored with with professionals who i think can bring to it for example the expertise you could bring to it but i'll tell you what i've learned i've learned that most people probably have some degree of unresolved business in their childhood that has produced adaptations and in some cases many of those adaptations are very good and should continue but some of those adaptations are negative and that is malleable right so there's there's this kind of this view of hope which is you don't have to throw out the baby with the bath water you can again in my case you can take some of those adaptations which produce you know hard work discipline all of these things but you can get rid of some of the negative ones such as the negative self-talk the perfectionism all of these other things that created a very negative impact on myself and those around me so this requires very hard work and unfortunately um it's not something that lends itself to the faint of heart unfortunately at least in my experience i'd be much more curious at your experience many people need to be at a local minima you know not necessarily the rock bottom but close to a rock bottom to start to probe those things. Well i can i can tell you some of the things that i've learned partly as a consequence of public lecturing and and speaking to people constantly about how they might straighten up their life. The first thing i would say is we've run a series of studies on a set of programs i designed with my students and my my previous graduates my graduate supervisor Robert Peel and Daniel Higgins Peel was my supervisor and Higgins my student we developed a suite of exercises called the self-authoring suite they're at self-authoring.com and the past authoring program helps you write an autobiography and clear up that excess baggage and the present authoring program helps you analyze your faults and your virtues rather programmatically so that you can start to generate a strategy to rectify your faults and to capitalize on your virtues and the future authoring program which we've studied most intently helps you develop a vision for the next five years and if we have people do the future authoring program before they enter university if they do 19 minutes of developing a vision. 90 minutes that's all no preparation with no one reviewing what they've written the probability that they'll drop out falls 50% and their grade point average goes up 35% and it is tied to precisely what you described is that people need a reason to live and I also in this exercise we help people break down the reasons to live and this touches on another point that you made regarding relationships you can't be healthy psychologically in the absence of a network of functional relationships you need a partner you need a family you need friends you need business colleagues you have to be nested in a functional social hierarchy and so we walk people through this process of vision development we ask them what they would like to have in five years if they could have what they wanted and needed we ask them how catastrophic their lives would be in five years if they let their bad habits get out of control that sort of sets the parameters right don't do this and do this and then we ask them seven questions what do you want an intimate relationship what do you want in your friendships what do you want for your job and your career how are you going to educate yourself how are you going to take care of yourself mentally and physically what are you going to do with your time outside of work that's productive and generous how are you going to shoulder some civic responsibility I think that covers the fundamental domains those are places that people generally find meaning in their lives and the upshot of all this is that almost no one has an explicit strategy for their life and that's a catastrophe what do they say the people perish without a vision this is literally the case and this is precisely what we're talking about it but it turns out just as in the case of exercise you said you can get a walloping advantage from just going from zero to three hours going from no plan at all to a hastily contrived 90-minute plan well like I said that has that stops half the kids from dropping out of university and so there are there's a large body of research showing that these sort of writing exercises to clean up your past and to structure your future are salutary on the psychological and the physiological front so you can imagine there's a three prong approach to to health span right sufficient exercise appropriate diet and the development of something like comprehensive account of and vision for your life now and that would be relatively inexpensive and all things considered relatively easy to implement so you never know maybe we'll get smart enough to move hard in that direction as a society over the next couple of decades so I guess is there anything else you would like to tell people before we close we're going to turn just so everybody's listening knows we're going to and watching we're going to turn to the daily wire plus platform I'm going to talk to Dr. Adi for additional half an hour about the development of his interest in these areas over his lifespan that's usually what I do in in that half an hour period but is there anything else Dr. Adi of it you would like to relate to the viewers and listeners before we close no I think I think those are three great principles there and I guess the only final thing I would say and it kind of ties a little bit into the last one is there is an exercise I have my patients do called the marginal decade exercise so you write down on a piece of paper your age so I'm 50 and you draw a line extending across the page and you tick off at 10-year increments so 60 70 80 90 and then I do the same exercise for my kids so I have a 15-year-old girl 9-year-old boy, six-year-old boy and I tick those out at the same 10-year increments so 25 so the daughter 25 35 45 25 center and they're lined up okay and then I start to imagine when they might have kids so this is a little bit of guessing but I start to put you know grand kid one grand kid two grand kid three grand kid four okay and then I go to what is the actuarial expectation of my life which is you know low to mid 80s and I ask the question what would another decade buy me and on one level it doesn't look that interesting right it's buying me the difference between being 83 and 93 but if that 10 years is at a reasonable high level of function and let's be clear it's not going to look like it looks now but I define what that function is I still want to be able to walk up a flight of stairs I still want to be able to carry a bag of groceries I still want to be able to lift my suit case up I get I look down and I see what a difference it is in terms of those relationships it's a profound difference in the decade of that person's life and my ability to be a part of that life and for them to be a part of my life and I say all of that because it's the why that matters a little bit here right right right right well you know that might be part of the magic bullet relationship to preventions that well why you should eat junk food is obvious it's immediately gratifying and delicious so the why is a no-brainer it's the same with abusive drugs like cocaine we don't have to explain why people abuse cocaine we have to explain why all people don't abuse it 100% of the time because it immediately activates the systems immediate positive emotion so that's a no-brainer if you look at the alcohol cessation literature what you find is quite a pronounced multi-decade set of conclusions that show that if you want to stop drinking you need a reason you need to find something to do that's better than drinking and if you like alcohol drinking is pretty good it's a highly social activity it's not that expensive it's available constantly it's an anxiolytic it it's a psychoprotor stimulant for some people it probably increases opiate response so it's very rewarding well the problem is is that it you know it ruins your life over a multi-decade period and blows your relationships to bits but if you don't have a vision of yourself extending across that span of time then why the hell should you care and it might be the same on the exercise and nutrition fronts like you're not going to take care of yourself unless you know you have something useful to do and I've been talking to people all over the world about taking responsibility partly because if you take responsibility for other people it improves your relationships and if you have better relationships well you're much more resilient and you're and you have much more of an opportunity for positive emotion and so if you take responsibility you have a long-term vision of yourself as well and so maybe the psychologists and the medical doctors can get together and figure out how to ally the work on exercise and nutritional improvement with motivation and and produce prevention strategies that people will actually follow partly because they see a reason in following them you need a reason to make sacrifice you know yeah I think that's the cure I think that's the key point here and I think that's that's the part that's the point I'm trying to make with respect to emotional health which is if you don't have this why we're just not robots that can be programmed to do all those other things we have to have a reason and I think your examples are great ones virtually everything that is bad for your health feels much better in the moment so to say no to that you to to to offset the hyperbolic discounting problem of delayed gratification you must have something that is stronger than the immediate hedonic pleasure of either not exercising eating the wrong thing staying up too late you pick pick whatever it is yeah well you know when I want to have a banana split which is reasonably often I think yeah you know but I'm pretty happy to have physiological constitution that's a lot more like I a lot more like it was when I was 23 than I had when I was 50 that's pretty good deal you know and the value in that I suppose that marginal decade for example the value in that's palpable enough so that I think yeah well it is a sacrifice but it's probably worth it so that's the question hey what's what's it worth making a sacrifice for and it's a question you have to answer if you're going to put your life together and put your health together all right everyone watching and listening on YouTube thank you very much for your time and attention to the daily wire plus people for facilitating this conversation that's much appreciated I'm here in Boise, Idaho today doing this conversation daily wire always finds me a studio and a studio for my guests to the film crew here thank you very much for flawless experience um Dr. Adi I was very good of you to talk to me today I wish you the best of luck without living the book and in your own life and I would also encourage those who are listening to continue to follow our conversation on the daily wire plus platform we'll talk for another half an hour on more biographical and personal issues thanks very much everybody thanks Dr. Adi it's good to meet you thank you so much hello everyone I would encourage you to continue listening to my conversation with my guests on dailywireplus.com