How To Improve Sleep Quality, Muscle Growth & Daily Mood - Dr Peter Attia (4K)

what's this story about your son going to hospital and getting some insane medical charge for a tiny procedia yeah well it's it's unfortunately a very common story right where anybody goes to the ER and you know they end up needing a bag of IV fluids or something like that and then they get a bill for thousands of dollars and you actually look through the line item and you realize this is comical right you literally charged me $1,400 for a bag of normal sailing that costs I don't know somewhere between two and $3 um but it sort of speaks to a lot of the breaks in the um specifically in the American Healthcare System what is it why is it so broken what is it because it's a commercial Enterprise is it because it needs to be uh additional funds need to be brought in from places where they shouldn't what's going on it has to do with the complexity of a multi-payer system and basically the way contracts are negotiated between payers and hospitals and and you have to decide in those negotiations who is in network and who is out of network um that's like one sliver of one problem uh this this exists on on so many levels um but in in that case I think the issue came down to you know some very high deductible that wasn't met coupled with you know some out of network thing but the the truth of it is there's also ridiculous pricing so so there's a sort of a false sense of how much things cost in hospitals it's sort of funny money like we're going to really really mark up the price so that we can give you a big discount if you're in network right you know so you you see this across the board with all sorts of things in medicine and to rehydrate your son it cost like six grand something I can't remember the dollar amount it was so egregious um and again I it's infuriating to me when you keeping in in mind the fact that you know probably the average American would a hard time on short notice producing $1,000 and yeah I'm fortunate enough that I can produce $1,000 without uh too much difficulty but for the average person maybe 50% of the population that's a really big deal and that's a huge inconvenience right that means that changes your plans dramatically it means you're not taking a vacation that summer it means you're not you know not able to go out with your family for how long you paying off that credit card debt for ETC totally it's totally inexcusable I went to a tour in New Orleans 5 years ago and the guy that was taking the tour finished up afterward and I was asking him about the American Healthcare System and he said this thing he really stuck with me he said if you get hit by a car you'd better walk it off his point being that there are medical emergencies that can happen that can ruin your life by you having to fix them not by you not fixing them yeah um Healthcare is is the number one cause of personal bankruptcy in the United States no way yeah it's strange for me as someone who's coming from the UK right there are problems with the NHS don't get me wrong I have had my share of problems with the NHS but there's a social safety net that picks people up and it feels to me it feels barbaric to not you you don't get the privilege of healthcare like it's just oh you're so sick sorry like not for you it seems it seems very bizarre coming from the UK yeah and it's a little counterintuitive the people who are most impacted are not the people at the very bottom of the socioeconomic ladder here because those are individuals who are going to qualify for something called Medicaid uh which is meant to sort of you know provide for the people who truly have nothing um but if you go one level or two levels up from that to people who do have health insurance but they're grossly underinsured or they can't afford health insurance because yes they're working and yes they have these other expenses but they can't afford that um those are the people that are absolutely devastated by uh the system here and and again on the flip side of that I think on some metrics the US Healthcare System is hands down the best in the world it's not an accident that when heads of state you know kings and queens royalty you know whatever need the best procedure they're going to come to the United States um and and so on the one hand the US has the best to offer in terms of you know the tip of the spear in quality uh for medicine 2.0 but at the other end of the spectrum when it comes to cost and when it comes to coverage and accessibility it's uh it's the You could argue it might be dead last in the developed world look at where it all began at the wild west of America though your cardiac machine being powered by a nice water wheel of whatever it is yeah you talk about this I I really love this conception between uh medicine 2.0 and and 3.0 uh you've got a quote longevity itself and health Span in particular doesn't really fit into the business model of our current Healthcare System there are few insurance reimbursement codes for most of the largely preventative interventions that I believe are necessary to extend lifespan and health span and after our episode last year I went to Fountain life in Dallas preventative medicine right full body MRI brain angiogram heart Ang scan with contrast and a dexer and a microbiome and all this stuff and it made me realize why it's so it medicines backwards you're trying to fix a problem after it's happened as opposed to working out what's going to happen and getting out ahead of it it's wild yeah lots of people I think want to improve their mental Clarity one of the things that is top of mind is my attention my focus my ability to pay attention to the stuff that I'm doing everyone's a knowledge worker in some form or another now what do you focus on when it comes to improving cognition yourself um I think you know there you could I sort of put these into different categories right there's sort of the the the things you do to improve the environment of your mind so I think probably at the top of that list is is sleep uh so it's very difficult to cognitively perform well when you are sleep deprived and I realize that many people listening to us will think come on I can think of all the examples in the world I mean look at all these people who don't sleep and are still out there clearly doing very well um and the point is you never have the counterfactual for those people right what you don't know is imagine that person sleeping eight hours a night instead of three hours a night um I I am positive that they would be performing even at a higher level um I put exercise probably at number two uh I think it is again just a remarkable way to provide not just the obvious metabolic and circulatory uh food if you will to the brain but but also kind of think about the the endocrine side of that right so bdnf and things of that nature uh play such an important role in brain health um nutrition clearly plays a role and managing nutrition is important um I think anybody who's you know especially people who are really carbohydrate sensitive will will appreciate that the the the big peak The Big Valley that follows you know a big car Rich meal uh is going to you know negatively impact cognition so again we could build out a few more of those things but then I think there's kind of the environment with within which you work and and I think for me this is the bigger struggle so you know luckily I think I've sorted out the Sleep nutrition exercise side of it so my limiter tends to not be those things it tends to be distraction and busyness and doing too many things at once that's probably the thing that limits my capacity for high quality work or deep work is C Newport would describe it right what are the rules or techniques that you set yourself to try and maximize deep work time well I mean one of the things is I don't actually have any notifications on my phone except the phone if it rings and you know in this day and age nobody actually calls you so basically I'm never really interrupted by my phone it I don't get a I don't get even a vibration if there's a text message an email or God forbid anything stupid like social media so I have basically a phone that does nothing except vibrate if it rings that's it um and that turns and talking with people I realize that's actually seemingly rare a lot of people look at me like I have three heads when I explain that I don't have any alerts on my on any aspect of my phone um the other thing I try to do is set aside larger rather than smaller blocks to get work done so I try to schedule big blocks of time early in the day that are my quality work time so typically that is 7:00 to maybe 9:00 in the morning is always uninterrupted so there's never anything that's going to be scheduled during that period of time and I focus on doing whatever's so this morning I did the most important things I had to do during that period of time knowing that from here to my next meeting to my next call is only going to kind of dissipate my cognitive capacities yeah I uh I went to Dubai I fled the UK during lockdown and went to Dubai which I think is four hours ahead of GMT which meant that I could get up at 7 or 8:00 and I had four hours before anything happened and it was Bliss it was insane it was what it feels like to be jocker willing for a while and uh I now being in the US I'm 6 hours behind the UK which means that I wake up to the just this cacophony of you know things that need to be sorted and there's a video going out and there's email and there's all this stuff uh but yeah I think for me choosing in advance what you're going to work on and then blocking off a little bit of time even if it's just an hour like right I'm just going to do the one thing that is going to move and if you actually look at your day and say what would have had to have happened what's the one thing that would have had to have been done by the end of the day for me to look back and go success it's probably not that insane of a thing it's maybe the thing that you have a bit of hesitation or resistance to doing it's usually not that insane yeah it's not a massive list in order to be successful okay so uh what about when it comes to working environment if you are you sit stand desk are you take are you doing pomodoros what else from the productivity well it depends what I'm doing um but again I'm I I also need quiet to work that's another thing so I always kind of look at my daughter who seems to be able to do homework with music on and I did as well when I was in college I always had music on when I was doing homework I I wonder if I could have done better if I didn't but for whatever reason when it comes to what ever I do now which is usually writing um I wouldn't be able to do a great job with any distraction soundwise or otherwise um St yeah I like to be standing if I'm not on Zoom uh my the way my office is set up it's just a lot easier to be sitting if I'm on Zoom I also you know I think you know people ask me all the time like do you you know do you count your steps or how many minutes you're standing or sitting and the truth of it is I don't at all right and the reason is I'm doing so much other stuff that I don't really need to be particularly attentive to those things all things equal of course I'd rather be standing or walking than sitting um but but I don't tend to fix it on it you're ignoring dollars to pick up pennies if you're thinking about how much time you're spending standing throughout the day yeah and by the way I think that is valuable for an individual who can't make two hours a day to exercise but fortunately I've just made that an unbelievable high priority where yeah it's I'm always going to be doing the really important stuff during dedicated time what about supplementation or pharmacologically what are you using if you need to dial in focus a little bit more nothing um I well I shouldn't say nothing so I love caffeine although I I'm not convinced I'm really getting a benefit from her from it I am a very very fast metabolizer of caffeine so I probably consume 300 to 400 milligrams a day but if I don't nothing happens like I I can't appreciably tell a difference so for me it's I love the taste I love the ritual I love making coffee my wife loves coffeee it's the one thing I can do first thing in the morning that makes her happy uh you know so it's like you know you know it's it's so I don't I don't even though people would argue that caffeine of course is a cognitive uh booster um I'm not convinced I appreciate the the the metrics of that um I do occasionally uh put a nicotine patch in my mouth I probably get more benefit from that um truthfully and maybe I'm just not aware of other products the product I use I think is too high a dose so you have to it's a milligram pouch so you have to kind of time it because as you probably know nicotine is a very unusual molecule where at low doses it provides a heightened sense of awareness so it's actually concentrating you but then you actually cross over a hump and then nicotine becomes actually quite relaxing and sedating I didn't know that yeah it's it's an unusual molecule in and it has Behavior so um both of those properties are ideal it's great to be focused when you need to be focused it's also great to be relaxed when you need to be relaxed it's just you don't want those at the the same time so with these 7 milligram pouches and again there's people watching this that I'm sure are going to be like come on you idiot don't you know all this other set of products that are out there um I used to I used to enjoy gum more because you could chew two milligrams at a time which was really the right dose to just induce the focus um again nicotine is an addictive compound so I say I don't say this lightly um but for whatever reason I don't appreciate any of that so in other words I might have it three times a week for a month and then forget about it for 6 months and I don't seem to miss it in any way shape or form um and obviously the mode of delivery matters so you know I'm not remotely interested in yeah I'm not I'm not at all interested in in in that um it's it's got to be basically gum or a loing or something it's so interesting that the dose can take you from where you want to be to where you really don't want to be but it's the same or it depends like again sometimes if if you know and I don't use it in this capacity but if you really need to relax SE milligram slug of nicotine will relax you that just make want to throw up that would make me want to throw up everywhere I'm very nicotine sensitive yeah no that's a real issue so what about we're talking about there's one other compound that I add to the list although I rarely need it but if I'm doing a lot of time zone movement I will also lean on mafel okay and how would you use that for yourself just use it as a quick reset on circadian rhythm in the new time zone right so for examp thing in the morning yes so take it first thing of the morning of the new time zone which is not the new which is not my morning internally right so if I had to go to London tomorrow um and I had to be there for 48 hours and then come right back my strategy is let's say I'm leaving Austin at 2 p.m. so 2: p.m. Austin time is what's that 900 p.m. 8:00 p.m. depending on daylight savings so I would go put myself to sleep on the plane within 2 hours so that I go to bed London time even though it's 400 p.m. Austin time and I don't want to go to sleep and then what would you do to induce sleep kind of a whole long protocol but basically it comes down to how early did I wake up in Austin the day of when did I exercise what did I eat and then I'm going to try to shut off my adrenal glands with phosphole Serene um I'm going to take Trazodone a dose of a high dose of Melatonin which is not something I normally use to sleep and that's going to put me out what were the first two things that you mentioned phosphole Serene and TR and what do they do phosphaline uh inhibits cortisol output from the adrenal glands and trone is a funny drug it's um it's actually it used to be used as an anti-depressant in the 80s but it never really took off because it had this um nasty side effect of making you tired so as ssris and the like came on board it sort of fell by the wayside we now use it as a remarkable sleep drug it's incredibly safe and more importantly it doesn't just induce sleep it induces stage appropriate sleep it's a very helpful drug for people who um don't suffer from any initiation insomnia but who do tend to wake up intermittently at night either due to anxiety or you know just any anything that kind of gets people up trazodone basically buzzes over SM that out yeah okay so you've then taken that melatonin what sort of dose again normally I don't take any but if I'm looking for the hammer I'm going to take three milligrams wow yeah that is a lot I mean his just before we go on to how to them wake up when you get to London the levels of dosage that you can buy in CVS of melatonin it's crazy is wild can can you just give the overview of how the dose curve works for melatonin with humans well I mean what's interesting is physiologically the pineal gland doesn't make that much Melatonin right it's making um micrograms of the drug so I think the smallest dose I've ever seen that you can buy might be 300 micrograms like maybe there's someone out there that makes a of 3 milligram yeah that's probably the smallest I've seen maybe there's a a 0.1 out there I've got a uh a spray and each spray sublingual spray of it is3 okay yeah so unless I can like man to half trigger it there's no way I could get but most of the time you're looking at 1 to 5 millgram I.E 1,000 to 5,000 micrograms of this stuff and even 10 milligrams and the problem with that is it seems if if if you look at the literature uh and I haven't looked in a while but the last time I did doses north of about six or 700 micrograms 6 to7 milligrams tend to really suppress melatonin receptors in the brain and so as a long-term strategy it's probably a bad idea so would that create basically a physiological dependency yep so my I try to get patience off melatonin truthfully and reserve it for jet leg and for travel only and and not rely on melatonin as a as a nightly sleep aid but for but if you're going to I I want them to be as low as possible 48 hours I can't mess about here I need to hit it with a hammer yeah if using this example if I I want to fall asleep at what feels like 4:00 and wake up in s hours and then two hours later land in London and be functional and be 100% functional and then take that uh uh medel upon Landing what sort of dose of the mapel is that immediately upon waking yep right and what sort of dose any idea I mean I usually take 200 milligrams if I'm going to take it but mafel can be dosed typically the low end is 100 and the high end is 600 okay uh what about armadil I've heard about that comparable right y same thing yep what is I'm you're speaking to someone that's never taken mfil what's the sensation of it like uh it depends on the individual so I perceive nothing I'm just more awake and I'm I feel fantastic but I don't get a high from it I don't get any stimulation from it I know there are some people I can't tell you what fraction of people but but a non-trivial fraction of people actually experience a negative sort of stimulation effect from it oh like they feel like uh it probably feels like what a fedra used to feel like back in the day oh it's rushy yeah wow yeah now now again I would argue that in those people they're simply taking too much and that they're very sensitive to it and they might get the benefit without that negative side effect if they down the dose my wife for example can't take it but that's probably because she's only ever tried 200 and I would bet if she ever really needed it I'd probably give her 50 or 100 in 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with your first box by going to the link in the show notes below or heading to drink LM nt.com modern wisdom that's drink lnt.com SL modern wisdom talk to me about so that's mental Clarity in the now what about uh reducing cognitive decline over the long term I think it's the the two big ones by far I think first and foremost is is exercise um clearly the most efficacious data right so if you just look at clinical trials if you just look at mechanistic studies um exercise is the best intervention for the brain um I think metabolic health and highquality sleep would probably next in line so metabolic Health meaning being insulin sensitive good Fu fuel partitioning right being as far away from the diabetes end of the spectrum is possible um again if you have type two diabetes your risk of um neur neurodegenerative disease goes up significantly um and then it's all things that pertain to vascular Health Beyond what's already been stated right so if you look at you know again it's important to understand when we talk about dementia we are talking not just about Alzheimer's disease but the other forms of dementia Alzheimer's happens to be the most prevalent um but it's by far you know not the only one and so when we think about vascular dementia uh frontal temporal dementia and obviously Alzheimer's disease all of the risks for cardiovascular disease carry right over there so what are the things we want to do to maintain um low risk for cardiovascular disease low burden of lipoproteins low blood pressure uh low inflammation those are the big big big three and metabolic Health lipoproteins how do we get to low lipoproteins um usually pharmacologically truthfully because for most people to to make the lipoprotein level low enough that it you can Factor it out of the equation is not really achievable dietarily unless you're willing to go on a very extreme diet that I think for most people causes more problems than it than it solves so you have to you'd have to be really really fat restricted to do that and there are some people who can do okay on that but most people end up also being too protein restricted they end up you know eventually getting sarcopenia later in life there's a whole bunch of other imbalances that come along for the ride right okay uh blood pressure what are the big movers when it comes to keeping that in a good range the big two by far are weight and exercise weight meaning weight loss and uh and cardiorespiratory Fitness right so you're not this could be the jimro as many of my friends are that probably overweight in terms of what body mass they're carrying not doing enough cardio not doing anywhere near enough cardio getting out of breath going up a set of stairs struggling to touch their toes etc etc looking really great yeah and and so while we have a lot of great drugs to treat blood pressure just as we do for treating lipids your ability to impact blood pressure with uh quote unquote lifestyle is much greater and should always be first line what does V2 Max or uh resting heart rate make a bigger impact on when it comes to I me are you looking more towards zone two or toward maximal work to bring that blood pressure under control both there total cardiorespiratory Fitness and you can't really be very high in one without the other in other words if you really really really have a profound aerobic base you're going to have a decent V2 Max and if you have a really high V2 Max you have to have a pretty significant aerobic base and and I do think that most people would benefit from training those two in a ratio of 8020 in favor of zone two wow oh okay yeah I think you know again for the Jim Bros out there of which I am you know a card carrying member um just throughout your 20s it's so if you if you know what a push per leg split is and if you're enjoying going to the gym and getting jacked with your boys it is so low down the list of priorities for you to care about doing cardio like unless you're going to a bether in two months time and you're a bit fluffy and you think I I'm going to get up and I'm going to do intervals fasted first thing in the morning that's it like cardio's just not on the table it's true how many days did you spend in aa oh was that like if you live in the UK that's like Cancun right for living kind of yeah yeah so you've got obvious we Europe's on our doorstep so it means that uh mayorca magalo Malia zanti aappa AA so AA is the coolest one of the lot because it's sexy house music and it's cool and whatever whatever um but but there's a they said there's a rule of you can ruin any European city by putting direct flights from the UK there it's so true you hear these stories about uh planes that need to be turned around in the sky because you know they're too rowdy in the yeah way too rowdy and you think look at any British airport if you go Easter holidays look at any British airport 5:30 in the morning everyone's got a pint everyone parents have got a pint as they're going way cuz it's drinking is just such a inbuilt part of British culture it is in our blood literally but I think you know we spoke about this last time I think we're turning a corner with alcohol I think I really think we are I think that the way that people see it as this sort of go-to coping mechanism like the relaxation mode of choice the thing that alleviates social anxiety perhaps this is because people aren't putting themselves into social situations quite so much they're able to sit in the house a little bit more um but previous industry was nightlife and you know I speak to my uh ex- business partner and all of the guys I used to work with and the ly Larry sort of drinking culture has now been wildly supplanted by much more chill sort of brunches and and it seems to have matured a little bit more so maybe when I was in London last summer um I went to uh you know near around the Parliament and stuff and there was this great statue of Winston Churchill outside of a park what you know the name of the park I'm talking about it has a a statue of Churchill facing out he's the only one facing out I think all the other statues of great folks are facing in and it's facing um I'm blanking on the name of the tavern like Stevens Tavern or something like that and you know so the lore is that that's where Churchill held shop right because you had to be within a certain distance of parliament so that if you got called back to Parliament you could go so basically Churchill lived there he was always eating and drinking there and holding court so of course I had to go there and there's no way I wasn't having fish in chips and some pint of whatever and I mean I just did this every day even though I couldn't stand the beer but I was like I'm going to have fish and chips and a pint of whatever your finest unspeakable warm horrible piss water is but if Churchill did this I'm doing this I got from my tour manager I got a a Christmas present of the champagne that Churchill used to demand was at every lunch meeting and he made this company create a new sized bottle because a half bottle was insufficient and a full bottle was too much and you couldn't think so they made a pint bottle of champagne and it's this and it's got the lore on the back and it's beautifully designed and apparently it tastes like fizzy I haven't opened it yet I need to wait for a good occasion um it tastes like fizzy Apple water or something and uh yeah he made them imagine being the guy that goes to a high class champagne establishment and says this it's not quite enough with the with the half bottle I don't need a full make make me a new I mean that's the that's the power that you've got yeah you say that striving for physical Health and Longevity but ignoring emotional health could be the ultimate curse of all what do you mean by that well um you know there's a there's a there's this Greek mythology of a fellow I write about in the book tonus who who requests of the Gods uh immortal and he gets granted eternal life but not Eternal health and so he has this horrible curse where he's alive but he's physically decaying all the way into this decrepit NeverEnding State and so I think an extension of that is well if you're if your um emotional health which encompasses many things happiness the quality of your relationships any sense of purpose any sense of Happiness if that is in a bad place why would you want to live longer I mean you you're you're objectively suffering so why would extending that suffering be of any value um and again like you can you can play sort of thought experiments all day long so uh let's let's play one so um you know the little bit I know of you Chris you enjoy people right like you're not an antisocial human being so if I told you um Chris whatever number you think is the dollar amount that it's going to going to take to make you happy we're going to double it okay that's how much money you've got and whatever metric of your own physical health defined by how big your muscles are how low your body fat is how well you can perform let's give it to you plus 20% sounds good so far yep and um the only catch is you're the only person on the planet now now don't worry I've created a bunch of bots that will do everything so your standard of living won't go down like you're going to have Bots that will do anything and they'll provide your food and everything H how how happy is your life like how long until you kill yourself not long no because think about it like what are you doing right so that just gives you one example of wow if you took away my ability to interact with other people life is not worth living very few people I could imagine could tolerate that for a long period of time um so sure that's extreme but it's a great way to illustrate a point which is if you have every single thing imaginable but you have no connection to other people what do you have um so of course it doesn't have to be that extreme for the point to still remain one of the things that I've been thinking about a lot recently is um integrating of emotions because a lot of us that come from a productivity background or a biohacking background or a strength and fitness background we try to reduce The Human Experience down to metrics and numbers and reps and sets and stuff like that but the actual phenomenological experience of being a human is emotions it's what what does what is the texture of your mind as you move dayto day through the things when you look back at the day sure you might be able to say how many words you wrote or how much weight you lifted or how far you ran but the actual momentto moment experience of that isn't you logging things on a spreadsheet it's how your mind feels what what what's going on internally and I really think that that point about emotional health being everything else kind of being subjugate to that is really true and it's something that I think people gloss over so when when you conceptualize emotional health what are you what are you talking how do you think about the component parts of emotional health or an emotional health regime you know some of it depends on definitions and semantics and I don't for a second suggest that the way I do it is the right way or anything like that the the way we talk about it with our patients because we do um because it fits into a hierarchy of all the things we care about managing in terms of longevity risk so longevity risk is anything that is a threat to the length of your life or the quality of your life and this has to be one of those buckets broadly speaking there are seven So within this bucket I would say it's um sense of purpose satisfaction and joy achievement quality of relationships self-regulation distress tolerance th those are probably the biggest buckets that fit into that um and again you know Arthur Brooks who I don't know have you had Arthur on the podcast he's coming on in a couple of month oh yeah so you'll have a great time with Arthur because this is really a big part of what he talks about is the subset of this around happiness um and I think he I think he has a very elegant way of of thinking about happiness right which is that happiness is not a feeling anymore than the odor of the food you're consuming is the caloric macronutrient benefit the food uh and and therefore people tend to get a little bent out of shape if they don't quote unquote feel happy in a sort of positive veilance emotional sense um and I I think that's actually one of the most important things I've learned in the last couple of years is that I shouldn't confuse my feelings with my state of happiness and that that when I when I'm evaluating my emotional state through the lens of happiness I really want to go through these these more nuanced metrics around like am I am I living in a manner that is congruent with what I believe my purpose is my purpose first and foremost as a father and husband but then secondly my my my purpose as a doctor and then maybe my purpose as a public figure but but I feel like I do have a purpose and all those things okay and then like what is the state of my relationships where are my relationships good where Are My Relations under strain where are my relationships lacking in my attention um and then what am I pursuing that is giving me uh a a sense of satisfaction which which really requires um doing something hard and achieving a result like and I you know some people are more wired to need that than others uh you probably are I know I certainly am and my entire life has been built kind of around hard things to do as little you know side projects you know physical challenges sometimes sometimes business challenges writing a book something like that where you Toil and it's hard but at the end there's something you're you're proud of so anyway it's it's it's it's it's about accounting through all of those things um and I I look for some people it's easier than others there's some people that just naturally tend to find ease within those things and others who don't just as there are some people for whom it's much easier to do cardio and they enjoy it and there's others who maybe gravitate more towards strength training or maybe others who don't want to exercise at all as their natural default state do you think there's a difference between emotional health and mental health or is this just lexical wishiwashi um you know I used to use the two interchangeably um but I I don't know I mean I think in the book I talk about them as as sort slightly different and I talk about emotional health as this thing that we are talking about now and mental health is the pathologized state of disease so depression anxiety bipolar disorder those would be mental health things I again I I don't think there's a right or wrong to this as long as one is clear in what they're saying one of the things that I really appreciated about you was your openness you've spoken about this a number of times your openness about your own uh sometimes negative castigating inner monologue it's something that I'm incredibly familiar with as well myself what would you say to the people who have poor selft talk a scolding inner voice that reminds them of how they fell short way too often what have you learned about dealing with that and also about balancing that with your high standards for yourself about wanting to make a mark in the world but also needing to be able to give yourself self-love yeah it's an interesting question um I don't know that I could provide generic advice on the topic because it probably depends on where the person is in pain right now so I know that for me the message the the reason I was willing to engage in the discussion around changing the behavior was because the output of it was was was made clear to me right so once I recognized the link between my selft talk and my rage and I fully accepted the fact that I wanted to rid myself of Rage then I accepted the fact that I had to go and fix the selft talk so my guess is the only way to really try to convince somebody that um you're having an inner Bobby night which is what my guy was having an inner Bobby night that screams at you all the time is harmful is by helping them understand a clear path between how that behavior links to something that is hurting them in another way that is more obvious and I I think if you can't do that it's probably a little too abstract to just say you know you should be nicer to yourself I listened on recommendation from a friend to a 20y old nearly 20-year-old Tony Robbins awaken the giant within workbook on Audible it's about an hour and a half and I never read the original book and in it he talks about pain Pleasure Principle and he talks about bringing with decisions that you want to make or with habits that you want to change bringing as much pain to bear look at what this has cost me in the past look at what this is costing me now think about what this will cost me in the future and then turn that up to a thousand so my friend wanted to stop biting his nails so he thought about all of the times in the past that girls had sort of made an icky sort of move when he put his hands on then they'd seen them and how ashamed he felt about it at the time and about how this was going to hold him back in the future and how it made him feel like a juvenile and it was immature and then he went online to turn it up to a thousand and he looked at the worst photos that he could find of people that had bitten their nail these awful you know like bloody stumps of fingers uh and then he thought about the opposite he thought about how much pleasure could I bring to this how proud I would be if I'd overcome this thing that I'd done for 20 years about how much more attractive I would feel about how much more confident I would feel when I shake someone's hand or I put my hand on my girlfriend's leg and these sorts of things and uh I have to say it's incredibly powerful like to do that to bring to bear and what you're talking about is there is a inner Tormentor that kind of does a thing but it's all inside of your head and it's Upstream from some things actually manifest that you can kind of hold on to and do a thing so how do you get how do you get back up and how do you point the finger at what's actually going on well you bring to bear so much of what's happening in the real world but yeah it's I think this is one of the most common issues especially people that listen to this sort of a podcast you know they're high Achievers they want to do things they want to leave a mark on the world want to improve themselves but so much of that comes from like whipping themselves into submission all the time I'm going to castigate myself until I like bow under the strain of how much torment I've given to myself and but as you know it there's a real myth that you have to do that to perform well right um and and the myth is that you know there are plenty of great coaches who extract remarkable performance from their athletes without that behavior so and it doesn't mean you're not firm and it doesn't mean you don't have high standards and it doesn't mean that if the team absolutely shits the bed and doesn't show up that the coach isn't going to let them have it but that's you know that's very different from the constant berading and also I I think there's just a real difference in terms of um you know differentiating kind of um a negative behavior or a negative outcome from the individual themsel is the is the is the problem right so so it's one thing to say I don't like that I wasn't able to do X Y and Z that's a different statement from I am a worthless person because I didn't do comment on my my selfworth on how much respect I am owed by the world okay so take me through how you reprogrammed that selft talk I understand that you can have this thing the rage is Downstream from the whatever but what what did that look like what did going in and factchecking your uh very Stern inner voice look like uh it was it was actually a very deliberate set of actions CU I think you have to do actions and the easiest way to reprogram is through voice so uh I think you have to audibly reprogram a system I don't think thoughts are enough and so uh the exercise that I undertook uh about four years ago to reverse a pattern of behavior that was in place for more than 40 years was to every single time I had a moment of self uh what was about to amount in a sort of self cursing um situation I would I was to I was instructed to take out my phone and record audibly a a a description of what I would say to a friend had they just committed the same quote unquote egregious act okay so example would be if I'm shooting my bow and arrow and I'm really doing a lousy job of it instead of jumping into self-loathing I would take out my phone and record a memo speaking but not to myself but to my friend you know like if it was you what if you had just shot as poorly as I did what would I say to you and it I would I would be much more gentle what what were the sort of things that you it would be it would be you know and again you have to understand how strained some of these discussions are CU in the moment you're so angry y right it would be uh hey Chris I know you just finished trying to shoot today and it it just didn't go well at all um you weren't able to accomplish any of the things you wanted to accomplish I I know it's frustrating um I think you just have to accept a couple of things one is um you're probably a little distracted today if you're being honest with yourself um because you have a lot on your mind and you know truthfully it's a little windy today and I I it's just hard for those arrows to fly straight when the wind is blowing at 10 m an hour um and you know as you know from pre previous experiences like tomorrow will be a new day like you're going to come out here and do this again tomorrow and it'll be better and we're just going to go back to process and we're going to get it right and we're going to we're going to do a couple of drills tomorrow to instill that that was it you know it might be a one minute little voice memo I'd send that to my therapist and then I don't know 5 hours later something else would come up that would piss me off I'd burn a steak or something cuz I turn you know I got i' got distracted and left the barbecue and and inside I'd want to immediately eviscerate myself but instead I would pull it out and pretend that it was my brother who had just burned the steak and what would I say to him if we were at his house and he had just burned the steak how would I make him feel better about it while acknowledging that it sucks we don't have dinner tonight you know and and I would do that and after four to six months of doing this I know three to five times a day lo and behold I couldn't hear Bobby Knight talk anymore wow so it can it really turned the volume down it is in my life the single greatest example of neuroplasticity that I have ever witnessed and how old are you how old were you when you were doing this I'm 51 now so 47 dude that's wild yeah you wouldn't think it could change I think especially when you're talking about selft talk it is the internal physics of your system it literally is the texture through which you interact with your own mind and it's the fish underwater thing like you just yeah you don't know that it could be different and to think that it's as malleable as that and how sticky has that been do you need to drop are you having to go back and do this or is no i' I've never had to go back and do it and I've never heard the voice again now I want to be clear this doesn't mean I don't get angry what it means is a the frequency with which I get angry is a fraction of what it used to be the um and the duration or the blast radius is much narrower so the last time I got really pissed at myself or pissed at my inability to do something was I was in the simulator I'm trying to learn I'm trying to learn a new F1 circuit in the simulator and um for whatever reason there are certain tracks that are just very hard Silverstone is a very hard track to drive uh it's very hard to put a perfect lap together and it just really gets under your skin and so is IMA so Ima is a circuit I'm learning right now like learning in great detail right like I want to come up with a really cracking time on emila and I was down in the simulator and I was going through it and I just couldn't nail the last the second and third last corners and I would have these epic flying laps and then I would absolutely [ __ ] the bed in this corner and either off track spin or just lose so much time that I couldn't put a lap together and you know after I don't know an hour of this I just got super frustrated got out of the simulator and was like absolutely ripping pissed off but because I didn't indulge in any selft talk it wasn't like you suck how can you not do this which is exactly what that voice would have said in the past it was just oh I am so pissed that I am not able to do this right now like I'm going to come and do it tomorrow and by the time I got from my simulator room upstairs I had forgotten about it and that's the difference whereas before that would have stayed with me and I I'm embarrassed to say this it would have stayed with me for the rest of the day I would not have been able to shed that anger for the rest of the day and it would have leaked into everything I did uh whereas now in 60 seconds I it's not that I didn't remember it happened it just the emotion of it was had dissipated already in other news this episode is brought to you by Maui Nei venison Maui Nei delivers the healthiest red meat on the planet directly to your door first off the venison sticks are seriously delicious not gamey at all and unbelievably convenient to eat no one accidentally hits their protein goals and these little puppies will help you throughout the day if you're traveling if you're on the road or if you're just a rushed human like the rest of us these things will help you to hit your protein goals and ensure that you're get getting good quality meat throughout the day not only do they provide the most nutrient-dense and high protein red meat available they're the only stress-free 100% wild harvested red meat on the market also they're actively combating the environmental destruction caused by Maui's Axis deer overpopulation which literally looks like a wild fire from above so by eating meat you're actually helping the environment get 20% off your first order by going to the link in the show notes below or heading to Maui NE venisoncooking venison docomo wisdom and modern wisdom a checkout so I can imagine there's a number of people whose inner voice perhaps isn't as uh pharmaceutical grade as yours was or weapons grade maybe um but presumably that means that if they were to go through a period of this rewiring that dose could be less intensity would be less difficulty would be less like if your patient zero for having a really really bad inner voice that means that people who just want to make it a little bit better because it's a bit bad should be able to get there have you got any idea what what was happening when you're going through like what is it about speaking to the friend what is it about that increase of distance what is it about the saying it out loud and yeah you know I've never really I've never really thought about what's happening from a from a neurobiological perspective it would be it would be an interesting discussion to to have with someone who's smarter than I am um and or at least understands that more but it is again I I didn't do this because I thought it would work I really was like this kind of a dumb idea there's no way this is going to work and I'm going to just be doing this for the rest of my life and maybe the fact that I have to do this for the rest of my life is the Penance like for for my sins but I was like it can't work like again I just thought like it it's so ridiculous that I'm going to do this because like you don't what is the next thing you're going to tell me I can a foot taller if I think about it every day like if I talk to myself I'm going to make myself taller like I I thought that this trait was as immutable as a physical trait y yeah you did a insanely long or intense period of therapy at one point can you tell me about that um yeah I've done two uh so these were like residential therapy programs that I went to where I spent uh two weeks in the first one 3 weeks in the second one where you're you're in a full-time residential Place doing therapy 12 to you know probably 12 13 hours a day that's like um mind rehab it's like mental rehab yeah it's immersion right so so it's different you know the way I people say to me people who have felt the need or wondered if it was something they would benefit from have asked me and they said look you know is it the same as just doing X number of hours of therapy and I say it's not because it's it's it's sort of the same of saying like look if if you really wanted to learn Spanish would you be better served doing an hour a week with a tutor or would you be better served moving to Spain and not letting anybody speak English to you like the the the difference in speed with which you're going to get there based on total immersion uh is is very separate I've never heard of this before I didn't know this it's like a Meditation Retreat but for therapy i' never heard of it yeah and again these these programs and there's probably many of them you know they're very well structured right so it's not just it's some group therapy some individual therapy you know EMDR for trauma family history stuff you know it's very uncomfortable like there's nothing about it that's enjoyable so it's uh which you know obviously is sort of like a silent Meditation Retreat where you have moments of profound misery um and then moments of of of bliss this is probably more painful than that because you don't really have any Bliss um but you know the the people who who who lead these kind of programs are very special and they really they really understand how to how to they they can pattern recognize it you know the other thing that I think is pretty pretty valuable about these experiences is none of us are really that special like we all kind of think our problems are super unique like no one's is fill in the blank as me and it's just not true like we're all pretty ordinary and you know um I don't know I maybe that's maybe people hear that and think that no come on I am a special flower but it's like no we're not special flowers we're just kind of trying to optimize for our own you know well-being and the well-being of those around us in our tiny little world and um if I can suffer a little bit less that's great but there are lots of people who have seen my problem before and um and if they haven't seen it exactly they've seen a version of it it's an uncomfortable realization but it's one that I've arrived at as well this sort of it's kind of narcissism to believe look at how special and unique and and uh difficult to understand I am you could never it would it would take you easily a decade for you to be able to get inside the Cathedral of my mental pathology and it's not it's not it's you know and I'm I'm deep in the I'm in my therapy era at the moment as well and you know the ease with which someone who is trained can see your patterns and call them out for what they are and sometimes they have a name and you go I don't have that it's like someone accusing you of having a disease and you go no no no it's not that it's something it's not that what you just described to me is the name of this disease and as soon as that happens the kind of veils fall from your eyes a little bit about you being personally cursed I often think about that term personal cursed that you can understand why the Ancients used to believe that the gods used Mortals as their play things because the phenomenon of of of Rage or of lust or of whatever it doesn't just feel like some neurochemical imbalance it it's imbued with meaning right there is a phenomen ological experience of doing this thing it's not just the thing it's like more and to sit down with someone and for them to see you to really see you and to observe what's going on and this is why you know so much of my transition from absolute adult infant to like Manchild or whatever I'm at now was it came about from listening to podcasts because For the First time ever I got to hear people that were being completely open and honest about their experience and me going oh wow like other people have that thing this isn't just me I haven't been you know imbued with some unique army of One pathogen that like affects me in this way other people have a a very like cursive internal selft talk other people hold themselves to high standards but then also feel bad because they're not enjoying life other people and uh yeah to to realize that you're not as special as you think you are or your problems aren't as special as they think that they are is unique yes yeah yeah and there is usually a pathway a pretty well-laid out pathway of okay well where does this come from and then how do we look at it and then how do we move forward it's not that hard I wanted I I don't know whether I'd be able to do two or three weeks of of full-time therapy uh two hours a week is is uh heavy enough for me so coming out the back of that what was there an immediate change or was this something that required integration like going on an iasa Retreat um the the the two were quite different and occurred at sort of they were separated by a few years um I think the second one was more was more successful um based on the fact that the first one I left uh kind of against their advice right so they wanted me there for another four weeks at a minimum another two you'd done two I had done two and they wanted they everybody believed I needed a minimum of two more but likely four more feels like this is the worst case that we've ever seen bringing the doctor they're like clear that's like the mental equivalent of that yeah and I was like guys I'm definitely better and they're like yeah you're better than when you walked in but you're not better better uh and they were right I didn't know it at the time uh and I was wrong and I left and I left this was in 2017 and I left and I largely held it together until 2019 and then I kind of fell apart again and by 2020 I was completely apart and at the beginning of 2020 I had to I had to go back and pick up the pieces of what I should have done the first time at a different place and here this is a place that's a little more intense and they get most people out in a week and after a week they said you you really need another week and I I sort of saw them I I did I I was like one I had in the back of my mind the experience the first time and I thought okay I can do it and at the end of the second week I really thought I was there and they were like you're not there and I was like I was a little annoy I mean I was a lot annoyed actually um it feels like you're working hard you're making sacrifices you're trying to do better yeah I'm like I don't know what else you would want from me like what would it take for you to say I'm better and it's really interesting I on know you know I ended up staying for another week and on the the weeks there run Saturday to Friday is a week so it's seven days but the it starts on the Saturday is the program right and on the Wednesday of the third week which was the 19th of 21 days I was there was the was the real breakthrough and and and so they were right you know that's the point right like they I but I only realized it then and so that to leave then on the 21st day like you know and this was you know it was in Phoenix so it was a long drive back home which was a lot of time to reflect um it was it was it was very very different coming back I didn't make any of the mistakes I made made the first time and I had a great system in place in terms of therapy which which uh still exists to this day so I'm still doing therapy once or twice a week and um it's a it's you know it's the perfect Cadence because there are times when things are going when there's really nothing to talk about and it's just easy to say hey I got nothing to talk about today okay you sure yep what about this no all good great but I having those meetings always on the calendar um makes them the priority how do you think about pulling yourself out of a negative mood if someone wakes up on a morning and wrong side of the bed syndrome what would be some of the places that you would say look here's a few things that you can do that can reliably change your mood alongside all of the other stuff that you need to do within a day you can't just take the day off and fly to Cancun or something yeah so remember a few minutes ago I said one of the most important things I learned in the last year with respect to this was was is that I don't want to confuse the feelings of happiness with the I don't want to include the I don't want to confuse the scent of happiness with the macronutrients of Happiness borrowing from Arthur Brooks language um I think the other equally important thing I've learned in the last year and I I mean I've learned this maybe sooner but but I've really been better at implementing it is um feelings exist for a reason so to be clear I'm I'm not a person who believes that your feelings are right I think they're wrong most of the time but the point is they're they're never accidental something caused them yeah and I have to explore the something and and this is where I've become I think more Savvy in the past year which is when I get into a funk which I do I start to I don't ignore it I and I don't judge it those are two very important things so that used to be my playbook ignore it or judge it ignore it or judge it be critical of it or pretend it's not there and power through now it's and I hate to do this CU you sound like an idiot like Ted lasso it's just be curious and non-judgmental about it like literally just say ah Peter it you seem to really be irritable and you really seem to be lacking interest in things that normally interest you you you don't even feel like going out and playing with your kids like you're Sullen and this that and the other thing like what is that about let's let's let's just think about this like do you feel a loss of intimacy with this person are you afraid of this thing is there something that's a you know that that is causing fear are you afraid of losing something are you are do you feel humiliated like you start to go through very basic emotions that tend to be negatively vean and you you go one layer beneath them and interestingly I mean again it's one of those things where if you told me this 5 years ago I would have said that's impossible that I could ever figure it out but I tend to stumble into the why and and then you can start to problem solve oh I'm actually all of this is due to my fear of this thing happening and then you can start to say well how rational is that fear and if it is rational is there something you could be doing about it and if there's not how can you brace for this outcome like so again it's the um and so so going back the feeling itself might have been totally ridiculous and totally false but it was a very important clue that took me back to figuring something out it's really cool to hear you talk about feelings in that way this is something I'm trying to learn a lot about at the moment I'm aware that it sounds like the most sort of performatively autistic thing to to say like I'm trying to learn how to feel feelings but like here we are and uh I really think that it's an area that is ripe for people who like to improve themselves guys and girls that are type A go-getters that want to try and Achieve things and they're completely missing one of the huge elements of this which is what's the day-to-day experience of your mind like not from a mindfulness standpoint because even mindfulness you can use that to not feel feelings very well like thought arises and we let it go it's like okay fine but where did that come from why did you feel that way and are you really applying all of the equinity that you can to just release relax and allow these things that's like uh taking a parasitol to stop pain it's like the pain is going to continue to be fed up to you what's causing that yeah and um it sounds so like fluffy and unscientific and I think another another part of it is especially coming from like a health and fitness side people want to be able to control the system if I eat this many grams of protein and lift this much I can expect this amount of muscle gain over a year given the but with emotions it's just this it's chaos right you don't have the same rigor when it comes to assessing them and when it comes to to dealing with them uh but yeah I I certainly for me it is the area that there is the most room for growth to be able to understand feelings feel them integrate them work out where they're coming from uh it's cool it's cool to hear that you've got to practice like that I think it's I think it's something that we need to be talking about an awful lot more well it's a journey I mean it's um I hope to be a lot better at it in five years but um and and I think the other thing I would really hope is that um I hope to be able to teach my kids because I think it would be more valuable than most things I could teach them right like I I do think that had I learned this in my teens uh I would have saved myself and by extension a lot of other people a lot of pain um and and a lot of that you know the the detonation so um yeah I it'll be interesting to see like at what point is is a is a child sort of mature enough to to sort of start to you know metabolize that learn how to emotionally self-regulate and all the rest of it in other new this episode is brought to you by marrick Health when I wanted to get my blood work done in America I asked around I did a ton of research and marck health came back as the best quality service that you can find and I loved it so much I reached out to the owner to actually partner with them on the show they genuinely understand training diet supplementation and pharmaceuticals they don't want to make interventions you don't need they will make suggestions that are minimum dose and appropriate for you and your goals and your age they're great it is literally like having a personalized bioh Health hacker in your pocket that understands you and your Bloods at all time you might have heard that I took my testosterone from 495 to6 and that was with the help of mar Health without using trt but by optimizing everything else that I was doing in my life right now you can get the exact same service that I got by going to the link in the show notes below or heading to Mari health.com slod wisdom that's MK health.com slod wisdom one of the other things that's been happening a lot recently is the rise in trt usage among young young men um maybe in part due to hoping to elevate their mood to improve the way that they feel what's your opinion on the what appear to be increasing numbers of young men using trt uh I'm I'm greatly concerned by it truthfully I I think it's um I I think again a lot of men I think don't understand the risks of trt and while to sterone is a very safe therapeutic I mean uh if if done correctly it's a safe a hormone as there is uh but you know if you're talking about a young guy who doesn't actually understand the impacts of testosterone on fertility for example later in life uh doesn't understand what a physiologic dose is versus a super physiologic dose and especially in the cases where guys have to get this stuff illegally um that then you introduce a whole new layer of contamination and uh all sorts of things like that so so net net I'm a little concerned um maybe a lot concerned I also think you know there are lots of clinics opening up that are kind of trying to circumvent some of these issues and again I I I think they're I think their their motivation is to capitalize on an obvious interest but they do so without uh you know necessarily A nuanced approach to how to do this take me through the risks of trt what are they high level so it depends on the on if we're going to talk about trt done correctly do you mean literally trt testosterone replacement therapy or that and its more uh malignant offshoots where people start to push dosages and stuff but take us through you know the range well I would say let's start with what's sort of known in the medical world right so we'll start with kind of appropriate physician administered testosterone replacement therapy for an appropriately aged individual for an appropriately aged individual at an appropriate physiologist dose cool okay so the two big risks that people have historically been concerned with are prostate cancer and heart disease so an increase in the risk of prostate cancer and an increase in the risk of cardiovascular disease both of these have been studied extensively and I think we can make a very strong and compelling case that testosterone replacement therapy is not increasing the risk of prostate cancer at all and it may in fact be decreasing the risk slightly um I've done an entire podcast I think two podcasts on just that topic that's how nuanced it is um but again we to give you just one example when we have a guy who has undergone a prostatectomy for prostate cancer he's had his prostate removed um we will still use testosterone replacement therapy in that guy so think about that you have a guy who had prostate cancer you will still give him testosterone replacement therapy if it's warranted or indicated post prostectomy now do you do it and shut your eyes and never look again of course not you're still monitoring his PSA every three months and you're going to look for any sign of recurrence and if there is infective occurrence you would immediately cease it because what we do know is testosterone would feed prostate cancer but the point I'm making is around initiation is there any evidence that testosterone replacement therapy initiates prostate cancer the answer is no there is not and there is some evidence to the contrary the cardiovascular disease question is a little bit more difficult and the data are little bit more muddled but on balance they come out in the direction of trt does not increase the risk of cardiovascular disease now there's a big trial that was completed last year called the Traverse trial that gave men uh AndroGel so topical testosterone and followed them for I want to say three or four years and there was no increase in the incidence of ascvd atherosclerotic cardiovascular disease but there is so so at face value that study was taken to mean look we have one more study the biggest and best that demonstrated no increase in the risk of cardiovascular disease with trt so the debate should be settled once and for all um I did a podcast on this wrote a long newsletter on this and the long and short of it is that's a in my view that's a slightly premature conclusion because I don't think the Traverse study was done perfectly uh most importantly it um did not give men a high enough dose in my view so the men started out very hypogonadal with a total testosterone of somewhere between 1 and 300 nanog per deciliter but they were only replaced to about 600 nogs per deciliter and while that's a reasonable rate of replacement I don't think it represents what's happening in the world yeah I mean we replace patients to higher than that we replace patients to 800 or 900 we're technically tracking free testosterone and not total testosterone but usually to get somebody in the rain of where we think a good free testosterone is we will see a total testosterone uh that's easily in the 800 900 nanogram per desil range so it's possible the Traverse trial only answered the question does low dose or as one of my analysts put it does testosterone light replacement therapy increase the risk of cardiovascular disease and I think there we can say the answer is probably no okay and what about testosterone replacement therapy when it's done badly yeah so I think if you even think about it in the medical setting I think testosterone can be given to very super physiologic levels and I see patients getting super physiologic levels all the time they come into our practice they've been treated at some tea clinic and they walk in with a free testosterone of 35 nanograms per deciliter um you know which is like twice what you would consider reasonable and you know part of the problem is we don't really know at the long everything goes out the window with what I said earlier now can I say that that doesn't increase the risk of pro cancer initiation I can't say that CU I don't have the data can I really say that doesn't increase the risk of cardiovascular disas no I can't it's also by the way creating a lot more Arroyos so these people are making red blood cells at an alarming rate and they need to be monitored very closely for increased blood viscosity is is that uh I have a friend of a friend who donates blood every month is that that's why because they just making to much and it's too thick correct wow I mean good for the blood donation people yeah and again the question is if you have to give blood every month if your bone marrow is so revved on that you have to give blood every month do we run the risk that you're going to convert into poemia Vera at some point which is a disease now where all of a sudden you can't shut that process off so it becomes self- sustaining even once you've come off the TT yeah again I'm not suggesting that that's happening what I'm asking is we don't know right and and there's just a big unknown there the other thing is once you start to get into these super physiologic doses you start to run into other issues around a lot of estrogen and a lot of DHT so you'll see these men who are on these super physiologic doses of testosterone also showing up on five Alpha reductase Inhibitors which we could talk about why I'm not a huge fan of those and on aromatase Inhibitors which I'm also not a fan to stop gyno and hair loss yes right and um obviously I'm not I'm not a guy who takes hair loss very seriously but um you know I I think it's a mistake uh to take a five Alpha reductase inhibitor for hair loss I think there are far better strategies if it matters and um I think you know even though the risk of uh finasteride syndrome or post finasteride syndrome is low it's not zero and it's potentially irreversible and this is this is I think in a young man taking finasteride again if you've been T if you're listening to this and you you're on finasteride and you have no issues you're fine it's something that if you hasn't kicked in within you know 6 months it's not going to kick in but um we do we do see men who have like a permanent loss of libido this is reported inid syndrome is yeah so so basically there's something about blocking DHT that might not be a great idea permanent loss of libido would be bad um what what else haven't we spoken about when it comes to exogenously increasing testosterone levels fertility yeah well there's another thing that I I think is when you yeah fertility for sure right so at um once you give exogenous testosterone um you're going to cut down on endogenous production including sperm production and therefore you're going to see a reduction in fertility and at some point that's retrievable uh and at some point it becomes more and more difficult to retrieve so it depends on the person's age when they start and what their testicular Reserve is but you know generally speaking two years of exogenous testosterone can spell the end of endogenous production and therefore a lifetime dependency which again we do that all the time like if a guy is old enough and decides it's time to go on trt we fully accept that and there's no risk of being on Lifetime tea for life within physiologic doses but for a guy who's young that might be an enormous risk and and we you know we see this all the time where guys who are doing this in their 20s decide they want to have kids in their 30s and they can't what else haven't we said about the risks of trt um I think there's another method of delivery using uh chopine and en en chopine and these are drugs that have the advantage of preserving fertility uh they work by inhibiting estrogen receptors in the hypothalamus that trick the brain into thinking you need more testosterone so now the brain uh via the pituitary starts producing more follicle stimulating hormone and lutenizing hormone and you end up increasing endogenous production um and again I I might be an unusual skeptic in this regard but my concern with that approach typically centers around yes you raise testosterone but are you getting the full benefits of testosterone because I think one of the benefits of testosterone is the benefit in the brain and if you're now blocking estral impact in the brain um certainly anecdotally there's questions about whether you're taking away some of the benefits of testosterone including mood and libido would you have any concerns for people being on Clomid for a long amount of time is that something that you think shouldn't be used um I would feel very strongly about people not being on Chopin or Clomid for a long period of time for another reason which is it really increases the production of a sterol called desol um interest so and the reason for that there's a lot of problems with that including potentially an increase in the risk of atherosclerosis increase in the risk of cataracts and things of that nature so I think long-term use of chopine is probably not a good idea the drug was never intended to be used long-term it's a fertility drug so it's intended to be used short-term and I think short-term uh rises in desol are not problematic but lifetime increases or many years of increase I think would be and there's a drug that was there's a drug that increased asmol levels in the 50s and 60s that was actually pulled from the market because of the increase in cataracts and the increases in cardio vascular disease what what about these I I went to uh prospera in Rowan which is one of these Network States there's no FDA uh jurisdiction there people are doing experimental ftin Gene therapies the dudes from Tiny Circle are doing all of this stuff it was it was fun it was like I didn't get injected but I I I got to see kind of the stuff that was going on but I was with uh two peptide scientists one that synthesizes and one that uses them incredibly heavily with clients and stuff and they were telling me about is it uh bt101 or something there's a a particular peptide that is able to induce testosterone uh from the brain which sounded like Clomid but without this particular feedback mechanism are you familiar with any of these not that one I'll find some I'll find some info and put it to you okay so let's say that we're going to go to the other side of the fence now there are guys listening who want to naturally improve testosterone production what are the big movers what would you suggest I mean it's going to sound like a real um crap answer I don't think there is a bigger way to naturally increase testosterone than adequate sleep and reduction of cortisol I I I think hypercortisolemia stress probably has the greatest negative impact behaviorally on the endogenous production of testosterone probably through the pituitary uh gatal axis and um you know how much can it move the needle you know probably to the tune of three or 400 nanograms per desil um so if you're not sleeping well um and you're under a lot of stress it's it's very easy to end up hypogonadal um and therefore fixing that I think is far more beneficial than sort of the the Litney of supplements out there that may or may not have marginal benefit so the for now for women there's a different answer but for men I would say that that's the answer the hard charging dude that's you know maybe mid 20s crushing it in the office going to the gym maybe partying on a weekend once or twice bit of alcohol whatever whatever uh this becomes kind of vicious feedback loop which is precisely why men are looking to things like trt because of how hard they're potentially pushing themselves during the week yeah and I think that you know so so to that guy what I would say is why do you want to replace your testosterone so let's say he goes gets checked out and his testosterone is 300 nanog per deciliter which you know probably puts him at the 10th percentile uh for a man his age so undoubtedly that would qualify as hypogonadism so the question is do you want to fix that because you don't like the number and or or is there a symptom we're trying to fix and if the symptom is what we're trying to fix then I would say let's fix that symptom I.E poor energy poor moood poor libido let's fix that symptom by fixing these other things over here and by the way along the way we might also improve your testosterone but I um you know again like I guess I don't treat that type of patient so maybe someone who does is listening to me and saying well you don't understand and you know that guy even though he's only 24 we're never going to get him out of that spiral if we don't normalize his testosterone and you you know again that that wouldn't be my Approach but I want to be mindful of talking about something I don't do for a living what about women yeah I think with with with women we have one more trick up our sleeve which is DHEA um so again doing all of the normal behavioral stuff but it's it's it's a little harder to make the connection in women um but but and this is something I actually learned kind of recently because I used to be very dismissive of DHEA because in men it has no effect whatsoever um but DHEA of course is what allows for adrenal production of testosterone and the reason it has no impact on men is if you increase a guy's testosterone by 40 milligrams per deciliter which is about what you're going to get from adrenal production if you maximize it you don't move the needle at all so taking a guy from 300 to 340 is doing nothing but if you took a woman from 40 to 80 what's a typical woman's range well it it depends by age and it also somewhat depends on where she is in her cycle but um I would say you know normal for a young woman might be 60 to 100 NS per deciliter yeah so if a woman is you know symptomatic and she's 30 and you take her from 30 up to 70 with just the addition of oral DHEA like that's a win are the risks um I mean the biggest risks for women at that level are you know the side effects I would say right so you're looking at increase acne maybe body hair at that devil at that level you're not going to get any of the other real risks that we see with t women yeah cliteral enlargement voice deepening and all that stuff you're not going to get that at those doses we'll get back to talking to Peter in one minute but first I need to tell you about momentus you might have heard me say that I took my testosterone from 495 5 to 1006 last year and two of the supplements I used throughout that were FID doio aestus and tonat Ali I first heard Dr Andrew hubman talk about these really impressive effects which sound great Until you realize that most supplements don't actually contain what they're advertising momentus make the only NSF certified for doju orestas and tonat Deli on the planet that means they're tested so rigorously that even Olympic athletes can use it and that is why I partnered with them so if you're not performing in the gym or the bedroom the way that you would like this is a fantastic place to begin to naturally improve your testost own and there is a 30-day money back guarantee so you can buy it try it for 29 days and if you do not like it they will give you your money back plus they ship internationally right now you can get 20% off everything sitewide by going to the link in the show notes below or heading to Liv mous.com wisdom using the code modern wisdom a checkout that's Liv m o m n t us.com wisdom and code modern wisdom a checkout have you got an opinion on the noof fap movement that's something that's put forward as a potential solution for guys with low tea I'm sorry I don't even know what it is let me teach you about noof fap this is my speciality it's uh men purposefully abstaining from orgasm either from themselves or with other people why because it's an internet subculture and the internet likes Trends and this has been a what does it have to do with the tea situation that there are guys out there who have created a link between the frequency of ejaculation and their masculinity both inverse relationship or direct relationship the more that you the more that you do it the more your energy is sapped I see got it have you ever SE has this ever been clinically observed in any form I can't say it I if it has I'm not aware of it what a shame geroscience researchers report an astounding case study of a 93-year-old with the physical fitness of a 40 year old this was the rower that I wrote about a few weeks ago tell me the story of this yeah it's an interesting fellow he um was not a lifelong athlete at all right so that's the beautiful part of the story in my book if you're if you're listening to this and you're a normal person so was he and he just kind of took up rowing like like classes rowing classes you know you go you get on a rowing machine and you just sort of do it and he just took such a love to this thing and got so good that at the rip old age of 93 I mean I honestly I think think his V2 Max um I don't remember if it was reported in the article or if we tried to back calculate it based on his times but I mean he at least from that perspective from a rowing perspective would have the fitness of a of a great 40-year-old now I don't want to misrepresent and say that he's a 40-year-old because he's not right he doesn't have the muscle mass of a 40-year-old although he does have very low body fat right so if if I if I recall his body fat was probably 6 15% which is outstanding is his muscle quality the same as yours no um you know would his coordination uh or fall risk aversion be the same as yours no but but look the point is when you compare him to another 93y old he's clearly functioning at a level that's you know in totality I would say at someone in their 70s and to me that's that's the game like I'm way more impressed by and interested in that guy than I am in any influencer I see doing any feet of strength running any like I don't care like I don't care what you can do when you're 40 I really don't I really care what you can do when you're 90 how long was he training for decades I mean this was not so he'd fallen in love with running would throwing it in 60s or something yes exactly okay and he'd accumulated this capacity over time yeah so think of him like a guy who you know didn't really accumulate much wealth until he was 60 and then started investing but was an amazing investor and a consistent investor and compounded and compounded and compounded and in his 90s he's a billionaire and it's sort of like w wow how did this guy just become a billionaire in his 90s well I mean he did all this incredible stuff for the past 30 years now the good news is you can start that at 30 and be a ridiculously fit 60y old and by the way you'll be a ridiculously fit 90y old as well yeah it's it's cool to hear stories like that because I think we've turned such a corner with our understanding of health and fitness within the last even just communication about anything it's emotions meditation history philosophy whatever but there must be a number of people especially like my parents generation who feel a bit miffed about the fact that God if I'd known this when I'd been able to hold on to my health as opposed to doing it now when I'm in my 60s that sucks but you have this example of a guy who did do that in you know what would be considered serious later life especially for an athletic career to begin or health and fitness regime and has shown just how powerful that is like that's I think that's very ins it's a very cool story yeah so he's he's kind of like the poster child for this centinary into cathlon I that I love to talk about right it's the it's the it's the mental model for what what I train for what our patients train for and what we really kind of care about give me your thoughts on Brian Johnson and what he's doing I don't know him have you been observing any of the stuff that he's done with blueprint with the supplements with the lifestyle I I try to ignore it why I I just have no interest okay that's interesting it seems to me I I spent a little bit of time with him he's been on the show and I spent a bit of time with him in um Honduras and uh I think he's kind of like the way I've come to conceptualize what he's doing for certain areas of the longevity movement is kind of like a scout in a an army it wouldn't do to have an entire Army of Scouts but I'm totally fine with someone doing something kind of experimental and maybe dangerous maybe not dangerous whatever and sort of going up to the you know the rocky Cliff Edge and looking out over the top and then coming back and kind of telling us what they've learned um but I'm both glad that I'm not a scout uh and also I don't think it's necessarily in everyone's interests to also be one too but it's interesting I asked him a question saying uh is he afraid of death given that almost everything that he's doing is focused on not dying how much from your perspective do you see the longevity movement overall and biohacking and health hacking and stuff being a kind of rehabilitated death denialism fear of death movement I don't know I mean that's a great question I I because I don't consider myself part of that movement I don't I don't want to speak for it I don't I don't really know I it's probably best to ask those who firmly put themsel as leaders of the movement um I know that I'm probably just as afraid of death as anybody else I I don't want to like represent that I'm some Monk here who's so at one with the universe that he can't wait to die I don't want to die it's and by the way I think it's less a fear of death and more a fear of not being here like that's the part that we can't really contemplate um cuz I don't you and I don't have a conception no nobody listening to us has a conception for what the world exists without that individual in it that's impossible to Fathom so um and the the the you know the older you get and the more you you know you have a family or things like that and you fall in love with things outside of yourself you then realize well actually what would bother me most about death is not being with my family yeah so that said I find the I find the focus on death avoidance to be futile and silly so I don't believe there is any scenario ever in which we avoid death I am 100% in the camp that says we are all going to die doesn't matter how much biohacking you do we are all going to die so can we delay that yeah I think we can um can we delay it by hundred years don't think so can we delay it by a decade believe so but I like to focus on health span and I think that that's I think that's the the real shortfall of of uh the healthc care system today is that it focuses so much on lifespan and it still does a lousy job extending it because it does it at such a low quality but what I think is really good about health span is if you really focus on health span how strong am I how much bone density do I have how good is my V2 Max how metabolically flexible am I if you focus on those things you will get the lifespan benefits along the way but you're but you're but the health span piece is actually harder so focus on that and you get the Tailwind of everything else how long do you think given what we have at the moment current human physiology current medical advancements all the rest of it if someone threads the needle and manages to avoid any sort of big catastrophes what you reckon is the ceiling for human longevity such a great question I mean we we know obviously to date what the ceiling is Right which is just based on the longest live Human which is probably 123 um so we know from the study of centenarians that who who do live on average right like two decades longer than the rest of us um they still succumb to the typical diseases and and if they don't you know they're eventually just going to get pneumonia or something right so even if you don't succumb to a disease at some point your immune system and or Frailty ultimately end you um now I'm I am excited about some really cool science that I think can bend the Arc of those curves right so if you talk about Frailty sarcopenia and you talk about immune sence I think there's some very interesting therapies that will occur in our lifetime that could push those things back tremendously so again I don't give up hope entirely that there's a way to dramatically increase lifespan um but I do find myself troubled by people who think it's going to happen on the back of like this supplement or this goofy you know hairbrained idea like the the depth of science that is necessary to do that I mean you are rewriting the entire epigenetic code to do that um like that that to me is the only way you can revert a cell back to its nent self so this is not like sprinkling a few yamanaka factors osm on a cell and just you know wishing that you're going to end up with a stem cell back there like no no no no no this is very deliberate cellular reprogramming and we clearly don't have the technology to do this yet but I it's plausible in our life time and then the question is how causal are those changes right that we don't know yet we know they're correlative right so we know what the methylation pattern in the epigenome look like on an old te- cell versus a new te- cell but what we don't know is did those changes cause the phenotypic change and if they did and they did alone and we reverse it do we get a young te- cell back again yeah so some super high dose of nmn or rrap a m or pick your compound of choice this isn't going to be able to go in and and rewrite that code no there's no evidence that it will it's very interesting yeah I um I think a lot about what people are trying to achieve with with the longevity movement actually that's one question so you mentioned before that eventually people so what is it it's funny I I I really I don't say this to be naive but like I even I'm so I don't pay attention to movements of this nature like what what is the longevity movement is this really a thing yeah I'm pretty sure that r/ longevity is the biggest subreddit for people trying to extend their lifespan I may have misrepresented them it may be Health span it may be you know there'll be some like very nice synopsis of it it will be living longer and better or something like that right uh but it's a movement of people that are biohackers Health hackers in one form or another many of whom will probably be massive fans of your work but you know so so again if it's people who are interested in being healthier but I I was thinking more about this idea of like immortality and well I mean you know Peter diamandis has this idea of longevity escape velocity that for every year that you stay alive there is an amount of time that you your life is extended because of improved medical stuff and Longevity escape velocity is living sufficiently long during this period that's kind of like the Dark Ages or the back end of the Dark Ages of medical advancement so that you reach this period where you're actually able to extend it infinitely sure um so that's a question I've got you mentioned that people in these blue zones or you know people the cenarius super long lives eventually they succumb to something Y is there such a thing as dying of just old age or is does everybody die of something well look there are some people who we would just sort of say they just died in their sleep and there was nothing really obvious wrong so yeah what gave what is that yeah I don't know it's could be an energetic problem right at some point their mitochondria literally stopped producing enough ATP for them to to to to respire um but you know I Hot Death yeah but I think honestly like I think many of those people are probably dying of a stroke or a heart attack and we're not doing autopsies on 104 year olds who die peacefully in their sleep we're rejoicing them we're thinking God I hope I can be so lucky yes yes yeah yeah talk to me about the because remember even if you did an autopsy on someone who had a heart attack if you if you didn't catch it and like depending on how long after the heart attack they die you might not see any evidence of it in the heart muscle oh right okay so you can show that that person could have died of it and you can show no evidence that that was what caused it exactly right so if a person is really really old and they have you know quite calcified coronary arteries with lots of plaques it's not entirely clear that you would find the exact place where they would have had a heart attack and um whereas it's more obvious if someone has a heart attack and they live for a while because then you have a beating heart and a piece of heart muscle that's dying and you get a contrast between the two right I see that's I didn't know that and again like I said most of the time you're just not doing autopsies on these folks talk to me about what you consider to be the basic supplements most people should at least be considering I'm aware that this is incredibly individualized but most people want to perform better have some good energy do well in the gym so on and so forth what are the areas in which most people should be at least looking at supplementation or the are there any at all I mean I think most people probably would benefit from magnesium so you have to then decide on which which ways to take it um I did a whole podcast on this because it is complicated and you want to talk about the speed with which magnesium gets absorbed are you talking about organic inorganic are you taking it more for perform and avoiding cramping are you taking it more for GI regularity are you taking it more for cognitive uh benefits so all of those would be different forms I actually take three maybe four different forms of magnesium so you're I'm keeping track of both the total Elemental magnesium I'm getting but more importantly the form I'm getting it in and how I'm kind of titrating each one to these benefits and what are you going for then um all of the above right so it's it's it's GI function it's muscle function which ones I'm taking yeah so slow mag is my favorite for uh as its name suggests slowly absorbing magnesium so you know minimizing any PVCs and cramping basically for a person like me who's very active sweats a lot you know live in Austin um then I take uh magnesium uh oxide which is kind of more the GI version of that and then I take magnesium L3 and8 which is the cognitive part of that so that's the one that gives you better cognitive absorption I'm trying to think if I take a fourth one I probably have some magnesium and something else I'm taking but those are the big three okay magnesium yeah uh creatine monohydrate at five grams daily in I usually again I don't think it matters when you take it truthfully but the most predictable and routine time for me to take it is during a workout so just mixing it in with electrolytes and water and drinking put it in with something else that you're already drinking exactly otherwise I'll forget to drink it uh I can't remember was it I think it was Tim Ferris who was talking about uh some benefits from much higher doses of creatine 10 to 20 grams a day have you looked at any of this have you seen any of this stuff uh yeah I mean look when I was a kid that's how you dose it you would load it you would do 30 grams a day for a week and you go 30 grams a day for a week and then down to five a day now my last look at this literature said that that was not necessary at all and taking five a day you'll very quickly get to your saturation levels and you're totally fine is there a size of human for him if you're 260 should that be a little bit more it's possible I I and if you're a20 woman 110 woman maybe would you keep it at five I mean I do and and the only time I sort of tell people to dial it down is if they get GI upset from it which some people do okay magnesium creatine um I think a lot of people probably could use a little bit of help with methylated B vitamins maybe some TMG um again I what's TMG trimethyl glycerate which is um basically we would use these to titrate homocystine levels so if a person's homosysteine levels are elevated um you can basically get their homosysteine levels normalized with methyl B vitamins now there we don't really have trying to think we have one study that speaks to the efficacy of that for brain health um but by but but we're what we're doing is using a proxy which is we know that homosysteine levels when elevated play a role in at least two diseases right dementia and dementing diseases and cardiovascular disease um and so by you know asking the question if you lower homosysteine levels do you address that you're asking the question indirectly is homocysteine causally related to those diseases or not um and looking at the neurodegenerative side it appears more likely that it is and there's a very clear mechanism for how homo sytin um could be causally related in cardiovascular disease Visa its impact on endothelial function and endothelial health but I would say that like like that's kind of a soft recommendation um I've got one copy of c677 RT I I I you know how many people I've met in my life who have the wild type for both MTHFR genes and you have to keep in mind how many people I've looked at in the past 15 years y um I've seen two people that have the wild type so everybody has has one of the Snips on these genes they they're I don't I actually think they should be the wild type truthfully I don't even I think we've got it backwards well we had to when we form we recently did a reformulation of of neonic to drink and uh I was like guys can you just check we're using natural folate for this right we like yeah we are I was like we're using methyl cobalamine right we're using methylated B12 yeah we are but you just don't realize how many especially if you are thinking about homocysteine levels if you're thinking about how you're taking B vitamins in you're not thinking about that it's totally not oh this could be like folic acid or this could be the non-methylated version of of the B vitamins really interesting um I take thumin what's that it's activated cumin circumin yeah it's basically a a more liberated form of circumin so more bioavailable liquid no capsule cap yeah what does just more expensive uh good question I don't I don't remember the dose it might be 300 milligrams but I'm not sure okay um you it's amazing for how often I'm asked this question you'd think I would know this better um there there's other things I just don't recall them magnesium yep creatine methylated B vitamins if appropriate to bring homosysteine in line yep cumin Orin thumin special cumin I used an absolute ton of cumin when I I red in Achilles four years ago and uh I went through playing Cricket the the British way and um I just threw the kitchen sinking it was covid I had nothing else to do uh so I asked every person that I could how can I keep inflammation down how can I blah blah blah blah blah so uh tb500 uh bpc 157 every tart cherry juice like any waving Sage over the top of it making a incantation at the full moon all of that stuff I did all of the things and uh the recovery was actually actually really really good if anyone ever considers blowing out their Achilles doing it during a pandemic is actually a really good time to do it because nothing else to do and I grew it back ni it's probably the injury I'm most afraid of it's 12 months of full very intense so do you have a sense of why it happened so I went back to as many people I mean this should be a public service announcement if you used to play a sport when you were in your teens and you're now 35 or something and you think I'm going to pick that sport backup very very slowly reintegrate it the number of friends that during their teenagers played basketball and then decide to go and play basketball now that they're 34 and they've spent the last two decades gaining muscle in the gym and they're nearly twice as heavy as they were when they played this and within the first couple of games they blow out in MCL the number of friends I've had it's like a list of friends that have done this just in my friend group uh and for me I was did one training session to play cricket performed sufficiently well during that session that I got invited to play on the Saturday and then with a very limited warm-up as normal sort of Club Cricket is uh stepped out to bat and was having so much fun it was great the Sun was shining my dad was over the far side we slowed the halt of wickets that we were losing and I was like this the first time I've picked up a bat apart from the net that I did on the Wednesday this the first time I've picked up a bat in over a decade and I'm like 35 not out I'm playing really good shots and I just pushed a single through the covers on the right hand side and set off to run and then as I I felt something weird did you hear it no but there was shouting at the same time uh from the the players on the the Fielding team and then as I went to put my right foot on the floor it was like if you tried to step on a an inflatable water bed on water and it just went like that and then the bastards ran me out so while I was laid on the floor like this in the middle of in the middle of the pitch they went and picked the Bales off which meant I didn't get like a whatever isn't injured like DNC did not complete or whatever uh they actually ran me out which was fine that's okay uh I think the reason that it would have happened was we' done shuttle runs on the Wednesday I wasn't doing a massive amount of like high PLO stuff and then when I set off you're wearing spikes on a very hard uh surface and it's digging into packed dirt which is what the strip is that you're bowling on and I pushed the shot through the covers and then set off with my back foot heel would have been a little bit off the ground so calf would have been lengthening as I'm Contracting and then it would have just hit the floor and went and that was me for you know 12 months uh 13 days and then got uh did you complete tear yeah full Detachment full Detachment yeah so got carried back over and I knew within 3 seconds I was like I think that's what that is and I just I didn't know enough about it if I'd known more about it I would have been more scared um but on the flip side of that my uh calf strength now and Mobility I've got really insane dorsy flection but for anyone that does do it or anyone that's done it recently yeah it's going to be a long rehab or if you if it happens in future it's going to be a long rehab and it's going to suck and you're going to feel a little bit unhappy about it but my function strength power everything is back to where it was including muscularity so if you looked at totally symmetric I overshot it on my right on the one that I busted and then had to go and do more work on the left because I built that one back up and um yeah I think good rehab plan take your time getting back to it and within 12 months you'll be doing everything that you were able to do and within two to two and a half years you won't know that it's there the only way that you can tell is if you look or if you give it a squidge cuz it's it's a like a girthy it's a girthy boy now but um of the things you haven't mentioned is Omega-3s oh thank you I do take that as well I'll keep you right um talk to me about anything else I should be taking CU you're going to remind me um Ronda Patrick was on the show big on Omega-3s really took me through some interesting stuff to do with eth Esters versus the reactivated version yeah tell me I used to know this and I have I don't know it anymore what are you taking I take Carlson's um I think there are a couple of Brands out there Nordic Naturals Carson that are pretty good I and I've gone back and forth with them and then we you know you test your levels to kind of see where you're getting the most bang for your um By Buck I don't mean dollar but how many of the things how many of the horse pills you have to take y do you know how many you're taking today I take three of the most potent one that they make which I think is called Elite or supreme or something like that whatever the most expensive one is presumably yeah but it's got the most EPA and DHA in it are you timing that par is it with a fatty meal um yeah I I I mean because I'm my compliance is the most important thing I have an AM and PM slide of of things that I take so I think I take one in the am two in the PM or maybe it's the reverse um so but the the point is I just know what I'm I used to take two and two but I've tit traded it back a little bit so I'm doing it based off what the EPA and DHA levels are in the red blood cell in the membrane yeah yeah it's uh and I'm sort of trying to keep it between 10 and 12% it's just for me cooking seafood at home is so rare like it's the it's all of the other thing red meat ground beef even liver is more likely to do that than for me to actually think I should buy salmon and I should it's just one of those things that kind of doesn't really appear to me and I often try and do it when I go out for food one thing I've fallen in love with over the last year is oysters dude I love oysters now I've become this this is what being an adult is you drink coffee and you have Oysters um but I really enjoyed that but at home it just doesn't Factor so for me supplementation when it comes to that I think is probably really important I think so one of the other things that people are quite obsessed about at the moment is water quality how long of a lever is this how much should we care about water quality and what it's being transported in and stuff like that you know I think it probably depends on where you are and what the risk of contamination is um uh you know I mean I think I take reasonable steps to ensure it but I'm also not so obsessive that my life spirals out of control around it now that said I mean we have we have a couple of reverse osmosis filters in the in the house aquatus um I don't know but I know that they meet the standard for filtering out all past so there's a there's a filtration standard that you have to go by and they plumbed in or tabletop uh they're plummed in cool yeah that's cool yeah so it's easy peasy so all change it once every six months so yeah all water bottles are you know we use glass water bottles they're all filled out of those things and you know the coffee pot gets filled out of that thing so the only water I'm drinking out of the tap that's not that is in the bathroom when I'm brushing my teeth um and taking my pills before bed or whatever um so I don't think I obsess over it I you know I I think that the two most important things you can do to avoid P fast from a drinking perspective past for the people that don't know yeah so there are these chemicals in Plastics typically that um I think we could make a safe case for um having negative Health consequences um now they're also found in things like Teflon and fire resistant you know clothing and things like that so they show up in other areas but for most people the the dominant exposure is through drinking um water in a plastic bottle um or contaminated City water if you drink it and you know I haven't had our water tested but I just sort of assumed like why bother testing it why don't I just put the filter in that gets that is known to get rid of it yeah I had Dr shanana Swan on the podcast she wrote the book countdown which is tracking sperm Decline and testosterone levels as well over decades uh mathematician turned closet epidemiologist I suppose and uh she was fascinating and her stuff is is pretty scary uh the impact of this one of the things that I didn't realize you know you you talk about declining testosterone levels and you think men but it's women as well in a big way uh and maybe in some ways given the fact that you've just got the adrenals creating testosterone for women you know less margin for error in some ways too um and she attributes it to Plastics I'm assuming endocrine disruptors a lot of microplastics um what are your Foods being transported in um you know she gave me this um really interesting example of people who get maybe raw milk or something like that and it's in a glass bottle it's from a farmer's market it's like was it manually pumped or was it pumped through a machine because that machine has got BPA in the pipes and the milk is warm because it's out of the animal so you're pulling the BPA from the pipes into that even though it's organic cow grass-fed open pasture no blah blah blah blah blah blah but okay what's the transport and it's just a Minefield to try and weave your way through um I mean one of the big ones for her and this was you know me and my entire 20s hot food in plastic Tupperware you know I'm doing I'm doing meal prep I'm eating healthily it's like you just put baking hot food into and there's no bpas in it yeah but it's like bfc's or it's bfc's or whatever the you know replacement was that they did for that uh so yeah she's got a big protocol that you kind of follow with regards to that but I think it's a big deal I think the endin disruptor thing is a a really big deal even if you don't talk about like hormonal birth control being peed out into the water supply and stuff like that there's you know even the way that it is transported to you is something that you should be concerned about as well have you looked at the psychological impact of hormonal birth control on women is this something you've done much research on um I have not looked at the psychological component of it but obviously the downstream endocrine component of it we deal with a lot in in our female patients um especially as they you know those who have been on it for a long period of time who are then becoming per menopausal and as you're transitioning them to HRT obviously one of the uh results of long-term um oral contraceptives is a significant rise in shbg so as their sexor binding globulin goes up and up and up their free androgens go down for a given level so you you kind of have this issue where even if they you normalize their testosterone or estrogen they might actually be physiologically experiencing less of them so that's you know again but definitely not something I consider myself an expert in the uh Dr Sarah Hill wrote a book uh this is your brain on birth control she's an evolutionary psychologist but um it's really wild I I think a friend has a a great question which is what is currently being ignored by the media but will be studied by historians it's a nice frame what are we kind of overlooking at the moment and I really think that hormonal birth control will be one of those things that um there was a recent Scandinavian study that looked at you know we've got this declining female mental health problem especially among young girls like 40% of American teenage girls have persistent or regular feelings of hopelessness it's like this real maab apocalyptic sort of language and um I always ask this question cuz I had Jonathan he on the show and he was social media or and comparison and blah blah blah but I was like how has anyone factored in the base rate of what increasing levels of hormonal birth control usage has done to like how much can this be contributing and this and has that changed significantly since 2010 maybe that's that's what needs to be looked at but because that's really I mean I think the argument in favor of Jonathan's argument is that when you look at the total takeoff or nose dive if you will of mental health for especially girls it coincides really perfectly with the exact introduction of you know Tik Tok not Tik Tok but Instagram smartphones and and and social media so unless there was a different type of birth control the question is was there also so a birth control change great question uh I think I don't think that there has been a change I think it's anything it's going to be kind of like just a steady linear adoption of of these of these drugs but what you don't know is is there some sort of predisposition some sort of psychological uh um raw materials that are more susceptible is this being able to magnify the effect of social media of social comparison uh and Dr Sarah Hills works so I mean it's fascinating the the change that women have in the kind of partners that they go for both on and off of birth control uh the um level of testosterone that they prefer on a man's T-shirt at the same time the libido and the sexual uh not only libido sorry uh their level of sexual satisfaction with their partner which also is indicative of partner choice and how effective that is and I mean you may or may not have heard these stories but so many stories of women who get into a relationship with their partner when they're on get married decide that they're going to then have children come off and they're like I'm not really that attracted to my partner anymore you know they sort of exit this hormonal Fugue State and their kind of eyes are open and it's not a comment on their partner particularly it's just that they're in a a very different hormonal profile now and what they find attractive has has changed an awful lot it's wild I mean the research is is really really interesting interesting yeah totally unaware of that side of things what about Sun cream what's true about the safety of sun cream I hear a lot of demonization of it that it's dangerous that you can put it on your skin that it gets absorbed that it turns into all of these things but then also skin cancer not good what's your position on sun cream uh I'm in the process of learning an insane amount of this for a podcast I'm doing Al so I would I would say I have my thoughts now but they're they're going to be updated by you know a team of phds check out the drive in three months time exactly when when we get to do our AMA on this we're going to visit really two questions that are both going to elicit a ton of controversy this so the first is how clear is the uh role of the causality of sun in melanoma so again that might seem like a stupid question to ask um but the answer is not entirely clear um so what is it about the Sun that increases the risk of melanoma is is the risk of melanoma increased for example in sun exposure that does not result in a burn or does it have to result in a burn does it have to result in a severe burn does it have to result in a burn during a certain period of your life all of this is unclear um it's a lot more clear the relationship between Sun and basil cell carcinoma and scamma cell carcinoma I don't know what that is they're two other types of skin cancer but they're non-lethal because they can't metastasize so you know to be afraid of skin canc really means to be afraid of melanoma that's the one that can kill you um and so that's going to be the first part of the podcast is really exploring that relationship and then the second is going to be the Deep dive on all of the SC all of the uh you know sunscreens out there and so sort of mineral versus chemical and um what what's you know to to the best of our ability to understand it what's the what are the real risks uh if any of of either of these types yeah does an awful lot of very vehement uh push in both directions I think for this I can imagine I'm we're certainly not doing this because we never do anything to sort of step in a pile of [ __ ] but I there's no question that this is going to be inflammatory but what do you think what else would be I mean perhaps surprisingly uh talking about Sun cream uh like you know real Hot Topic it's a you know a war zone out there what are the other uh really spicy areas that you might not have thought about you start talking about pollen or something and it's it's a a real war zone what is that um I mean anytime I talk about lipids and heart disease and uh dietary fats and stuff anything to do with diet that's always that that always tends to be quite inflammatory uh because of course you know anything that's diet related is sort of very tribal and and religious um I think HRT is a somewhat polarizing topic though less so now than when I started talking about it you know when I really started talking about HR um most of the medical establishment viewed it as bad and dangerous and I think more and more the doctors are coming around to realize that you know the Women's Health Initiative was such a flawed study uh that it's you know responsible HRT is a great thing for women um uh what else is really controversial look I think you know vaccines I did a I did a i interviewed again named Brian deer and we went deep down the MMR causes autism claims and that's obviously a very polarizing and controversial topic what did you find uh I can see absolutely no evidence that the MMR vaccine is linked to autism and instead I see an incredibly fraudulent guy in Andrew Wakefield who committed you know literally scientific fraud to um confabulate data to to make that case uh and it's an awful shame uh like I'm not going to sit here and tell you that all vaccines are are great or that every vaccine is without risk that's that's not the case um but the MMR vaccine is a very important vaccine that's a vaccine that saves an unbelievable number of lives and an unbelievable amount of misery in children um and it's a vaccine that's targeting a particular uh set of viruses whose vmia is indeed driven by the exact mechanism by which the vaccine Works in other words there are certain vaccines where vaccination actually impairs transmission right that clearly wasn't the case with covid um so you could always make the argument that there was no public reason there was no Public Health reason to vaccinate people with against covid it was it was an individual reason that's not the case with MMR the nature of how the virus spreads is indeed impaired you got kind of a tragedy of the commons type thing going on yeah so um and again I mean just the entire topic of vaccines is so controversial but was it this controversial five years ago do are you aware no I I mean this particular topic was for sure mm has always been has always been vac over it seems like there's you know like vaccine skepticism well now now I think it's been Amplified right so I think that the CDC uh did itself absolutely no favor didn't shower itself in glory no the the way they handled everything around covid has made it um has actually done a disservice to I think vaccine science and um it must be absolutely infuriating if you're a vaccinologist or trying to work on these you know life's work genuinely yeah trying to do things to make people better to avoid illnesses to you know like eradicate disease and then for the CDC to [ __ ] the bed in such a huge and and not just the CDC obviously uh in such a huge way that well that that that anything in medicine becomes political is a tragedy and it's you kind of would want to believe that medicine would be the last thing that could be political but you know just two weeks ago I wrote a piece with our team for the newsletter about something that I never imagined Could Happen which was the American Heart Association deciding in what is clearly just a political kind of woke agenda that race will no longer be considered a risk factor in cardiovascular disease so they're taking race out of risk calculators now you know in their defense I suppose their argument is that well race is a proxy for socioeconomic status so you know but what they argue is that race is a purely social construct with no genetic component and this is just patently false um and the you know I could have written 10,000 words on this with all of the counter examples of where race is indeed a genetic construct and with it come risks and why we would deprive ourselves of a tool that allows us to better risk stratify people uh just makes no sense to me regardless of your political ideology so unfortunately to see that medicine is also becoming corrupted by ideology is um is very sad but not surprising I suppose I had this idea of toxic compassion so the prioritization of short-term emotional Comfort over everything else and the ground zero for this would be uh body weight has no bearing on health and mortality um well you know you don't want to make people who are overweight feel upset you don't want to sort of activate in them this sense of oh maybe I'm not maybe I'm going to die sooner or whatever but by not communicating that to them they're literally going to die soon like you run the risk of these people getting into all manner of problems because of this prioritization of short-term emotional Comfort over long-term flourishing the truth accuracy and the same thing goes for this yeah the same thing goes for you know race has no bearing on your vulnerability to different types of Health outcomes I I have zero medical training and I know that that's false I know that there's disperate outcomes disperate risk levels for different diseases in different race groups like it it's wild it's really wild and the fact that you're starting to play about with People's Health you know I I don't think that there's as much truth in the the accusation as uh some people might want or that some people might claim but you know the doors coming off Boeing planes and stuff like that Bridges Dei diverse hires that are doing you know this isn't commentating for the New York Times and moving culture with culture is not nothing either you know people's beliefs and how they see the world is not nothing but when you talk about medicine and airplanes and bridges and going to space that's you're really crossing a threshold there into the yeah science and engineering really needs to be free of of anything that that puts Merit Anywhere But at the top and and Perfection of knowledge how warranted is the huge Panic about processed foods in your opinion well again I think the devil's in the details right the word processed is a bit of a troubled word because if not for processed foods you and I would be pretty different right now like I mean processing is what allows a lot of what we eat to exist um so we you know I don't know that that processed foods by itself inherently implies things are bad there are lots of processed foods that are excellent food what would be an example oh I mean like you know you take like a a a really natural form of like wild I mean I'm being completely biased cuz it's a company I'm an investor in but the first thing that popped into my head because I had it for lunch today was like you know our venison sticks right this company I'm an investor in called Maui NE venison so sorry for the pl we got no we' got some over there yeah so you know that's that's a processed food right like it had to be you know dried and put into plastic and salt had to be added to it um so but look that's a very healthy food now is it as healthy as if I had just killed that deer and just eaten that deer right there probably not you I could probably make a case for why it's not it's probably got more salt in it than it should or and and those things are there to preserve shelf life um but but that's clearly a processed food that I wouldn't put in the same camp as a bag of Pringles so you know we can get into the secondary term of you know hyperr processed foods and and and we can talk about that but but I still think it's better to just talk about things from first principles as opposed to labels that are mildly descriptive but not granular enough um to provide real value so to me I would rather say you know a venison stick is more healthy than Pringles rather than say processed food is good or bad understood what about hyper processed foods is is that worthy of the the current moral Panic you know I don't know I I I mean again it comes down to there are enough Foods in that category that are really totally garbage right there's there's no doubt about that and the old adage that as you walk through a grocery store most of what's in the aisles is indeed garbage most of what's on the perimeter is indeed good um and most of what's on the inside is processed and most of what's on the outside is not so um look I I feel lucky because I enjoy cooking I have the means to do it I don't have to rely on processed foods because again you know one of the things that makes processed food so appealing is not just the taste but it's the convenience and the caloric density per unit dollar right you can get a staggering amount of calories per unit uh uh you know monetary unit um at a great convenience right it's uh so so the further you can get away from what I call the the the the sort of standard American diet where it's with its four pillars right which is you know has to taste really good has to be really cheap um has to be scalable right you to be able to do it at Big scale and it has to be really portable and storable so the solution to that problem is processed food um and the further you can deviate from those vectors the better have you seen this activist letter against Kelloggs so the guy called Jason K bill akman um signal boosted this a couple of days ago uh this dude called Jason C filed an activist letter against Kelloggs demanding that they stop selling what he calls inferior versions of the product in America there's red 40 and blue one and yellow five there's specific colorants that uh exist and there was this comparison chart and you had what's in the Canadian version and what's in the American version and why is it different according to him um because it's not being enforced that there was a EST made or that um so Canada stepped up and made a request for a better product I it should have been done based on what I know it should have been done across the board Kellogg said that they were going to get rid of these things in America but they didn't and it seems you know all manner of conspiracy theories then ensue they're in bed with the FDA someone's being given a backhander um this is indicative of America's total Blas careless nature with the food that is being consumed by there you know pick your explanation of choice but it seems that there are certainly colorants and some other um ingredients compounds that are in specifically Kellog but let me ask a naive question like what Kellogg's Product would you consider good for you anyway like what Kellogg's Product should we be eating I don't know I don't know I'm not even asking rhetorically I just don't know enough about their products but like well it would be seral you know a lot of children having these fro loops and stuff like that first thing in the morning yeah I mean again I I would I I don't mean to sound like a cranky old guy but why would we want our kids eating Froot Loops in the morning like I mean again it I know I just a moment ago said well I it sounded like oh maybe he's waffling on processed food right but I'm not waffling on a particular food like there you know Froot Loops might be a treat like for dessert but like on on what planet would you say we're going to start our day with candy cuz that's all it is it's just candy that you add milk to you've got kids yeah what do you for the parents out there they iers and coffee sadly for breakfast probably not going to happen what do you feed your kids that satiates their desire for for their pette to be mu Bueno but also so when they do eat cereal they eat cereal that's a little less sweet so they're going to eat Cheerios now maybe Kellogg I don't think Kelloggs makes Cheerios do no I think that's Nestle maybe yeah so anyway so that you know Cheerios is kind of their cereal uh you know they'll put berries in it yogurt applesauce again processed but it's you know you can get an applesauce that literally has the only ingredient as apples right um and that's that's what they eat um is that typical breakfast what's a typical breakfast oh bacon sausage like they eat venison um eggs like we make them little you know like egg wraps toast you know again like it's not like I don't want to paint the picture that my kids are these little organic vegan machines like no no they're but but again like what I just described as I think a far healthier breakfast than you know eating Pop-Tarts or eating uh Loops what are you actively trying to avoid the sugar um yeah I mean I I I do think we try to be mindful of sugar and crappy junk food and just limit when they're going to have it and how much they're going to have um so my kids by the way I mentioned it a minute ago but my kids love Pringles so they can have some but they're not going to eat like this many of them right they're going to have that many of them because we buy like little mini packs of them which are not cost efficient but like we're not optimizing for that right we're optimizing for a small serving size where it's like one and done and dad's not going to eat it there's this uh yeah that's true because once they've opened it it's now yeah there's a tube of Pringles like I'll eat it it's the trickle down effective right okay I didn't think about that I didn't think about the fact that if you get your kids something that they like that's also something you need to deal with now being in the house it's so interesting I um it's also sometimes you just go out for stuff as opposed to keep it in the house right so like you know we we went out for ice yeah we went out for ice cream the other day and it's better because you just go out you get it over with you're done you come home but to have ice cream in the freezer every day would be a problem for me yes I need uh Geographic distance is the best discipline uh for me when it comes to diet what about is there any truth or have you looked at disregulation that comes from Wi-Fi networks and airpods and stuff like that have you have you looked this yeah I've looked into this a little bit I got to tell you I don't buy it I I mean I if if there is a signal it's a really small signal I think this is a bit of a majoring in the minor and minoring in the major problem I am amazed the number of times like I'll put up a post on Instagram where I happen to have my airpods in and I'm I'm giving a post about something meaningful like you know here's an interesting you know thing that you ought to think about for exercise and there's always 10 people that chime in I don't even know if I can follow you anymore the fact that you're wearing you know those airpods and I'm like first of all I don't care if you follow me so please unfollow me but like what is it like to go through life so stupid where you actually think that that matters more than the fact that I'm trying to explain to you something that is in order of magnitude more important for your health like and I just feel bad that like there are people again it's just it's majoring in the minor and minoring in the major I I don't know there is an obsession there seem to be certain areas of Health that people love to lock on to you know the specific type of artificial sweetener that goes into a beverage the the ionizing or non-ionizing radiation that's coming out of your airpods the the Wi-Fi signal 5G towers that you live near and bits and pieces like that meanwhile show me your deadlift right or show me how fast you can row a 2K right exactly yeah like why do you do you know your almi and your V2 Max and Elaine Norton and I had this discussion once on the podcast which was like you shouldn't be allowed to even comment on these things on social media until you do 100 push-ups like literally but before you type it into your phone do a 100 push-ups and then get up and then you can type your stupid comment about my airpods or about this sweetener or about like just like get it right get your Boulders in place first please Lane uh continues to just pick fights with people on the internet I'm I don't have the um Constitution to do what he does but I love watching him just go to war and he's in the comments and he's fighting back in the comments and like hey man fair fair play that's not my bag and I can't do it but yeah he uh yeah I I avoid the comments at all cost but I and I rarely even look at them right so but but every once in a while like someone will like my team loves to send me the most ridiculous comments um you should put them up you could pin them on the board and have like a a wanker of the month a wanker of the week there we go you can have that one for free Peters team um um but yeah the it's so bizarre the things that people hook themselves into very particular it's it's it's like an obsession and that's the thing that's the thing it's all Downstream from sweetness it's all Downstream from whatever and you're like dude I feel like you probably sleep 5 hours a night I think that you probably haven't processed I mean you definitely haven't processed many of your emotions cuz I can see it it's pouring out of your finger I have a friend who is so obsessed with these what I just basically call conspiracy theories of Health um and at some point I was like how much how much time are you on social media a day and he's like yeah probably like eight hours a day I'm like I've got a health tip for you and it doesn't have to do with the airpods Sleep one of the things that we haven't spoken about what are the most important strategy there's so much to do on sleep sleep actually one of the few places that doesn't seem to be too tribal uh you know like just sleep more maybe some people will argue whether you need to have magnesium L3 and8 or activated charcoal or whatever whatever whatever what are the most important strategies when it comes to Sleep Quality um probably regularity of schedule so you know the closer you can be to going to bed and waking up at the same time every day that's great uh duration so leaving room to sleep for a ient duration so in other words you can do everything right but if you're only going to give yourself 6 hours from the minute you get into bed until you have to be brushing your teeth in the morning you're only going to get so far um then there's obviously the hygiene that goes into sleep so temperature Darkness uh and stimulation before sleep so what what are you doing to get your brain ready to sleep again I always remind people there sort of three factors that are driving this right so you want Denine to be climbing as high as possible you want melatonin to be climbing as high as possible and you want cortisol to be plunging as much as possible so what do you what what do you have to do to make those things true so to make adenosine go up you have to be active right like adenosine is the byproduct of activity so the more active you are during the day the more your adenosine levels go up and then you have to say you have to you know put that down right that's a sleep signal melatonin is driven by light but but again you have to have the right circadian rhythm so you have to be getting the right time and doing it at the same time over and again which is why when I was talking about my travel schedule I have to force exogenous melatonin into the equation because I can't rely on the external cues but that's why I don't want people taking melatone and regularly I want them relying on the natural way to get it and then cortisol is probably the hardest one for most of us even if we because the typical biohacker gets number one and two but you're we're sort of missing number three which is how do I actually get my adrenal glands to come down to let me actually go to sleep and that's the one where again you can do it sort of with a you know a pharmacologic or molecular Hammer Hammer which is what phosphole Serene is doing but again I don't really want to have to rely on that every single night instead I want to get into a habit of for two hours before bed not engaging in anything that's going to be stressful to me so I'm not looking at my phone I'm not you know chirping on work emails and looking at things that are I mean I'm really kind of trying to be doing very little that would produce and if I am doing some work I'm not going to suggest oh I'll never look at my computer for two hours that what am I going to do you know I'm going to do something that's a little more relaxing or I'm going to you know watch some F1 highlights or something like that that's just pure Bliss but is not going to to to increase my level of of stress um and then we've talked about some of the supplements obviously that you can take there did you I don't think you mentioned about your dose of magnesium um I take two of the L3 inates which is I think that's 166 milligrams is what comes into okay I also use Trazodone 50 milligrams every night most nights um great sleep aid um and that's that's that's it no uh concerns about long-term use with trione no not a dependency drug that's good um when it comes to sleep hygiene room temperature core temperature tends to need to drop or at least it seems to help you fall asleep if there is someone listening who is having struggle uh trouble falling asleep they struggling to fall asleep and they're doing a 321 3 hours before they're not eating 2 hours before they're not drinking one hour before they're turning up screens they feel like they've got a dark room they feel like it's relatively quiet what are the other places that you would look at if someone's struggling to fall asleep and then also if someone is having those uh breaches if they're if they're finding themselves waking up throughout the night you got any idea what that could be caused by well if they're struggling to fall asleep sometimes I ask the question are you going to bed too early so you know there are different chronotypes of sleep there are some people who are truly night owls and they you know they're really not meant to go to bed until 12:00 or 1:00 and they really need to be getting up at 7 or 8:00 and if you force that person to go to bed at 10: because their spouse goes to bed at 10: they might really struggle to get to sleep and and and I there's a term for that when spouses are on the different chronotype um I forget the name of the term but um unhappiness yeah um I would also look to make sure believe it or not that a person isn't overslept so this is not an entirely improbable scenario where you see somebody who is sleeping too much they have too much time in bed and therefore they aren't building it up enough or or they take a nap the day or something like that and they haven't built up enough sleep pressure and so they're having a hard time going to bed of course you also want to rule out things like caffeine caffeine inhibits adenosine by the way inhibits the adenosine receptor so that's how for someone who's not like me caffeine is a wakefulness uh compound so that those are the other things I'd be looking through on the checklist on is making sure when was the less caffeine are you if especially if you're caffeine sensitive the halflife is actually quite long 9 hours yeah I think it's about 10 but yeah it's I mean it's long enough that you can easily get into trouble with it and what about if you're finding yourself waking up throughout the night is that is that just the same well no I mean I think that there and you know the question is why are you waking up because you have to pee then if the if that's the issue then what do you do you know why is that happening um if you're waking up and you're ruminating honestly I think the best tool for that is is cbti um cognitive behavioral therapy for insomnia very powerful tool and then there's a whole set of behaviors around that right so what what do you do when should you get up and out and disengage from sleep altogether when should you try to go back to sleep and and so so we're very liberal in our use of cbti with patients who are struggling with that one of the uh strange things that happened during Co I found myself going to the bathroom more frequently like having to urinate more frequently and I was like ah it's probably nothing doesn't matter and then it got toward what I uh ruptured my kiles and I was going into see my GP I was like the the classic male I will accumulate a number of different like medical problems before I then decide to bring it up like thing and I was like yeah I'm um I'm going to the bathroom a bit more than I thought it would and immediately it's like I've got prostate cancer I'm going to die and uh the doctor turned to he was like you are the fourth guy I've seen this week that's come and said this to me I said okay and he said what I think's happening and he explained this I'd be interested to know if you noticed this too with your patience during Co everybody started working from home this that they were all at any time within five yards of their kitchen they were probably caffeinating a little bit more because they could get themselves coffee as much which meant that they were just detraining their bladder and going to the bathroom more frequently who is there there is no boss looking over your shoulder saying you shouldn't go to the bathroom so this is again like kind of another public service announcement to guys maybe it's to girls too but certainly to guys if you're like oh my God like I've started having to go to the bathroom more and it feels like I can't I can't hold it in maybe I've got something wrong with me it's like this was exactly what I did so I got put on a a a Col energic um to like release the I don't know how I'm sure you understand how it works like make you need to go to the bathroom less frequently and then you retrain you do a period of retraining which I've now done and I full bladder capacity congratulations for me um but for it took six months wow it took six months for me to do that to really get myself back to like you know three-hour podcast like bladder capacity um my business partner came over my then business partner in The Nightlife stuff and I had my leg up on my thing cuz I was in Achilles recovery stuff and we had a 90-minute meeting and he went to the bathroom when he arrived and he went to the bathroom an hour later and I was like he came back in I was like dude I don't mean to pry here but you've been uh you go to the bathroom a little bit more than you would usually like yeah I'm really worried about it's like I think I know what's happening and uh sure enough he did he did exactly the same thing so I thought that was just such a it's so funny how that you draining like draining your bladder literally like there's a valve or something that sits above the urethra or whatever and it's like that hits a particular amount of pressure when there's pressure in the bladder it's like you need to go to the bathroom and you just detrain that and it becomes like so interesting yeah I was totally unaware of that yep and that was a thing that happened um on the other side of that though because I was on uh anticholinergics and they weren't having as uh much of an effect and they took me from I think 5 milligrams to 10 and I lost 20 IQ points and it was brutal and it was like you I love my thoughts being sharp and quick and being able to play with ideas and stuff and I forgot the name of a British Seaside town called Blackpool I forgot that for like two minutes during a conversation I'm like rummaging around in my brain trying to remember this place that should have come straight up and that was scary because that was I basically kind of induced short-term cognitive decline you you know like a reversible short-term it was that was really scary to me and that kind of gave me a newfound uh sympathy for people that are going through uh some kind of cognitive decline because it's it feels like there's a bit of you that's being pulled away and the thing that you use to fix the problem is the thing that's being taken from you so the fact that you're you know your cognitive horsepower what I'll search on the internet and I'll come up with a solution and I'll you know diagnose or I'll think about a a way to add this new strategy into my routine to make this better all of that the the raw materials that you build the solution with are the problem and there yeah there was just a whole real interesting period like six months of my life where I was like uh I learned an awful lot during that time one of the other things I think that's a big at least for me I'm focusing an awful lot on Good Health at the moment and this is like a whole other world for someone that hasn't been that reminds me of another I take which is uh pendulum probiotic okay probiotics kind of in the crosshairs a little bit at the moment what what makes a good and bad probiotic uh first it has to be alive which turns out to be much harder than than most companies appreciate so um if you're making Anor robes which most of the probiotics need to be Anor robes since those are the bacteria that you're actually trying to replenish in the colon um so an Anor robe has to be manufactured in an in a completely oxygen-free environment which is really hard to do I mean from a manufacturing process it's very difficult so most probiotic companies when they make their probiotic with the best of intentions think they're making Fillin the blank um but when they you know kind of count the units and tell you we have this many cfus or col Colony forting units um they're not actually checking if they're alive or not by the time these things get to you they're they're completely dead so um that's that's rule number one is you you have to actually you know buy it from somebody who knows what they're making and is um is able to to verify with more sophisticated tools that you're actually getting alive bacteria um or at least freeze I mean when I say alive freeze-dried and will come back to life when you ingest it um or will come back to a state of you know function um so I think that's that's sort of step one and then and then of course you know we're still very nent in this space and still trying to understand what to do um the probiotic I take is um is really rich in in a bacteria called acromania which plays a very important role a role in butyrate production so butyrate is very important in metabolism and short chain fatty acid metabolism glucose metabolism um and um this is a a probiotic that's actually been demonstrated in a small but but rigorous and blinded study to lower glucose levels hence it's called glucose control okay what else should someone that's never considered gut health before be thinking about lots of insoluble fiber this is this is the most important thing you feed your gut so you know for all the arguments why you know vegetables in particular matter this is the most important I think and and I think there are lots of reasons vegetables matter um but this might be the most important and it's the one that you can't get around right so you can drink a green drink you know I I love AG you love AG we can all drink those things and we're getting a lot of the vitamins that come in the vegetables and we're even getting the phytochemicals but you the fiber you can't get in volume in that you're not getting enough fiber you have to be able to consume um insoluble fiber to actually feed your gut so I I think that that's probably something most people are deficient in what are your favorite sources of insoluble fiber uh I love salad stuff right so anything that goes into a salad so lettuce cucumbers carrots celery all that kind of stuff those are that's probably where I get the Lion Share of mine is there any truth behind this if you blend vegetables and fruits together it changes the way that it interacts in the gut and it spikes blood glucose and it you don't get the benefit of the fiber thing um I don't know about that the only thing I know on that front is that bananas believe it or not might actually impair the absorption of other nutrients from other fruits and so don't put a banana in a fruit solid yeah or don't put a banana in a fruit smoothie might be yeah that that the it's preliminary and it's a very small study but and I don't really drink fruit smoothies so I doesn't really impact my life but but if if someone's really in the business of fruit smoothies I might differentiate separate the banana from the rest of the fruit what else gut health insoluble fiber big importance that means rely on vegetables continue to have as many cups as you can throughout the day yeah I mean I I I think that's sort of what I again I'm fortunate right that's the 80% well well no I mean I just want to be clear and say like I feel very fortunate I've never had gut issues um my gut T tends to be very insensitive to things that I know can cause people a lot of gut issues such as wheat and dairy and things of that nature um I'm impervious to those things it doesn't matter but that said if you're not impervious to those things then you've got to figure out what it is that is causing issues and sensitivities and get rid of it and the only way that you can really do that is with an Elimination Diet you can't do it with some stupid test that someone's going to charge you 600 bucks for that doesn't tell you anything you have to actually just take the presumptive offending agent out run that to ground for a period of time and then reintroduce it um I'm doing hardcore fod map at the moment yeah and uh it's actually not that bad it's not that there's still loads of foods that you can eat on FODMAP so I don't really mind all that much I mean it it's not exactly the most exciting diet that I've ever done but I'm holding on one of the other things that I was interested in talking to you about is motivation so there's all of these things that we should do and can do to keep ourselves living longer but there's other competing goals that we have as well and if compliance as said earlier is one of the most important things then you're you're playing this sort of this long game how do you think about the component parts of motivation and and compliance and sort of willpower to keep doing things whether that be from a health standpoint or from a work standpoint as well how do you in myself or in others in both um I think in myself um because I tend to be more um rational mind than emotional mind so in in in DBT you learn about this DBT dialectical behavioral therapy you learn about the synthesis of rational mind and emotional mind in something called wise mind and that's as you learn in DBT wise mind is the place you want to be like you're at your best because you're using the best of each of these components when you're in Wise mind um but different people obviously have a tendency to drift into one of the others more likely and I tend to drift more into rational mind and all that means is that data speak to me more than feelings and as such when I need to motivate myself I tend to look at the data more but there's nothing wrong with that there's nothing right with that there are other people for whom the feelings provide the motivation and you know I was actually having dinner last night with somebody and we were kind of talking about just that which is there are some patients who really all you need to do to help them understand why they need to do something is bring it back to their goals so it's a very cognitive motivation right like you want to be able to achieve X Y and Z to do that you have to do a b and c and anytime you deviate from A and C I just remind you about X Y and Z again that's me um there are other people for whom the relationship with that practitioner matters the most their trainer is the reason that they eventually want to be able to do this like they don't want to disappoint that trainer and the stronger that bond is the easier the compliance is um so again I think it kind of comes down to knowing who you're talking to and understanding what makes them tick and then that's what you can basically use to to sort of help people stay motivated and compliant what about navigating an obsession with perfection so as soon as you give people tool TOS that they can use that is an ideal against which they can begin to measure themselves and they can feel when they fall short from a health perspective and the pain self-induced pain that you feel from falling short can then induce stress which actually isn't particularly good for you in and of itself how how do you think about the Perils of over optimization and kind of not obsessing over those things and finding that balance well I think it's very important and and obviously the old you get the wiser you get and the more you realize that um you know perfectionism is uh you know potentially an evil master um but I don't know I think people sort of have to learn that lesson the hard way like I don't I think it's very difficult to teach people lessons until they're in pain and they have to they have to kind of learn like you know the cost of that is really high um and maybe I need to be it ALS it sort of comes back to what we talked about earlier right I mean perfectionism is just another manifestation of uh a maladaptive inner monologue so it comes back to how we talked about that which is if you want to resolve that you have to see the pain point you have to be able to link that thing to something that is you know hurting you yeah it's it's strange to think about the potential negative externalities of perfectionism because all of the benefits so immediate M you know you take pride in doing things right paying attention being precise and caring about stuff think all very good and the world will reward you for doing those things because there are people out there who either don't have the capacity or the disposition to be perfectionists in that way and that means that there is an entire blue ocean out there but again like we said before what are the like what are the psychological costs look I think they're and I think I think this is a it's a it is a dangerous addiction it is an addiction like any other um but as you said it's more societally rewarded and that makes it harder to Break um because the really destructive addictions you're not fooling anybody like including yourself like there's there's nobody in an alcoholic stuper who thinks this is really good crushing I'm doing so well right now and everybody is telling me how well I'm doing um that doesn't mean that it's easy to get out of that but at least Step One is is taking care of you're a big fan of compounding over time of things slowly accumulating and decre and stuff like that what is it when it comes to health and fitness what is it that people how how can someone who's in their 20s or 30s made of rubber and Magic never had a health problem you know like yeah you know medicines for like other people and stuff like that probably they go to the gym they probably care about diet but it's not got that real like I am investing for my final decade how can you bring that stimulus that realization that investment like from the far future Into the Now how can you motivate an idiot 20 or 30y old person to care about this stuff they have to go spend time with people in those in those later decades they have to they have to spend time around people who are where they're going to be and they have to see for themselves what that looks like and they have to decide for themselves am I going to be different than this and if so why like you know the first order response to that might be oh well that'll never be me well why why won't that be you what was this person like when they were 20 do you think that they were that different from you um so I think the more time you get to spend uh in the in the sea of old age the more you come to realize yeah I'm not that different like and and by the way I experienced this as well like I I I remember even a decade ago you know people talking about what it feels like to wake up and be just kind of sore and just taking a minute to kind of as you're getting out of bed like you're a little stiffer than you were and I couldn't really relate to it and now I can so it's given me a little bit more insight into oh I can I could imagine in 10 years it's even harder this is something that I've wanted to ask someone for ages and you're the perfect person there's a lot of talk and sympathy rightly I think given to uh women aging so much value is placed on youth in women but I do think that the discussion for men about how to age gracefully about how to kind of accept your slow physical demise uh I don't really hear people speak about that much how have you got any insights here either for yourself or for your your friends or your clients or anything like that well you know there's a couple things there right so first of all there is a sort of I think there is an injust asymmetry there which is I I do think um women seem to pay a higher price for Aging in terms of whether it's their view of themselves or even the world's view of them right I mean let's take an an example in Hollywood right so I think it's probably easier to be a to be a leading man for longer than a leading woman I would guess that is true there's probably data that could could could support that so does that mean that female actors are not as good as male actors or does it mean that you know female actors are punished more for aging than male actors it's probably the latter um that said uh I think you know I think when men are aging there might be different things that factor into it and and this might be one example but I I wonder if more men deal with regret than women because I wonder if more men engage in the kind of emotional stuff that we've discussed already today when they're younger and they they take into their older age things that they wish they did different whether it was with respect to how they were as fathers how they were as you know husbands whatever the case might be and I don't know maybe that's wrong but I but I do wonder if that there are differences in aging between the Sexes that that come down to sort of certain areas of socialization as well as biology how can we as men learn to deal with that decline you know we take pride in the mile time that we can run and the muscle mass that we hold and the leanness and stuff and yeah I don't think it's youth is much more prized in women than it is in men but I think the conversation also accounts for that at least in part and that's it's written into the cultural sort of rhetoric around women and around aging I don't think that this exists for men I don't know that it is but to your question about like how does one cope with the the loss of Aging because there is loss I I tend to think about it through the lens of how I think about health span right so when when I talk about health span it has three components um we've discussed them already but I I'm explicit in saying them now right so there's a physical component a cognitive component and an emotional component two of those three are going to decline as you age no matter what you do I don't need to tell you which two they are can you alter the course of their decline absolutely can you start at such a high high high place by working so hard in your 20s 30s and 40s and slowing the rate of decline that by the time you're 97 you look like someone who is 70 yes you can but make no mistake about it you are never going to look like someone who is 20 so in addition to doing everything I can to do that I tend to place more energy in the one that doesn't have to decline with age and maybe kind of rejoice in that one which is you know when I was 20 I was an insufferable miserable self-absorbed prick and I am so excited to know that when I'm 60 I won't be now I have to work really hard not to be to be clear it's not the default state that your emotional health will get better over time you need to work your ass off at it just as you need to work really hard to maintain your physical and cognitive Health as you age but the beautiful thing is you will actually increase as you a that emotional peace if you're willing to do the work and so my view is do the work in all of them and accept that this one's going down but this one's going up and to me that is true whether you're a man or you're a woman and therefore that is the single most important thing I cling to as I find myself having a little pity party over the fact that I don't like my body as much as I used to and I don't don't feel as smart as I used to feel and I hurt more than I used to hurt and I'm not as strong as I used like nothing about me today physically or cognitively is what it was 10 years ago and if I told if I told you otherwise I'd be lying yeah but I'm a way better human being today than I was 10 years ago and I know that I'm going to be a way better human being in 10 years than I am today what would constitute an emotional training regime for you if we've got you know V2 and Zone 2 and whatever for physical health what would the emotional training regime be well it it really comes down to sort of the there's the therapy right like those are your sessions in the gym and then there's kind of everything you're doing in between it's the you know the analogous thing would be being active when you're even not just in the gym and and the the lifestyle choices you make day by day so it's um how do I put into practice what I'm learning so um I don't know for I mean again I sometimes get embarrassed talking about this stuff because I I'm a little embarrassed to talk about what a what a horrible human being I used to be but um we're all friends here yeah um you know just like I really take joy now in in being less selfish with the people I care about and and to think about how selfish I used to be like everything revolved around me my health my work my this my that um and you know like yesterday for example my my my wife who had a long run this morning a 17 or 18 mile run she's training for the London Marathon so she was she had a long run this morning and you know she was like look you know can you go and pick up our daughter who's volleyball practice ends it at you know 9:30 and then you got to drive her friend home and by the time I get home it's going to be like super late and again normally she does that and you know and and that's just kind of like she'll do that pickup that night um and again this doesn't sound like a big deal so people watching this are going to be like what's he even talking about but in the past I would have like been like I don't know babe like I just I think you just got to do it because I got too much stuff to do but of course it didn't even occur to me of course I was like of course I want you to sleep like go to bed early let me go take care of this and I'll do this this this thing when I get home and I'll take care of it and again it's a very small example but it's the practice it's kind of putting into practice like how can I be a better spouse because of you know I I I don't want to be the selfish guy who the Earth revolves around um so even though that's one very small trivial example that happened to occur last night it it's like looking for those opportunities every minute of every day and looking for ways to be a better dad or a better friend or a better son um because Lord knows I've been so bad at those things for so long and and and and now I'm really enjoying the opportunity to to spend more time with my parents in a way that I never never did before cuz a they're not going to be around forever but also I know that it means so much more to them given that I have kids now too well also you have this degree of pride in knowing where you came from like you are and maybe I am too uh the emotional equivalent of a fat guy that got jacked you know like look at how terribly I was the awful condition that I was in previously and look at all of the work that I've gotten to now and you're again the same as the dude that used to be fat that now is like bro I did a I did a 5k park run this weekend and you're like well you know compared with Elliot Kip chog that's nothing it's like yeah but you don't know where I started it's like going and picking the daughter up and not thinking about it and wanting to be there to support the wife that's not that big of a deal it's like yeah but look where I started right and uh I'm learning that too I've got I have a number of pattern I'm also very cautious super cautious of like this is my new toy and I'm now starting to see everything everywhere I saw a tweet a little while ago that said um uh I just learned about recency bias and of all of them I have to say it's my favorite and it's a great meme right and like no it's the D and Krueger effect characterized right yes yeah I don't want to see everything that I do as oh well there's people pleasing again or oh there there's there's you with your blah blah blah blah blah um but it's fascinating and really is an entire new realm of life that I totally hadn't considered I you exper everyone's experiences emotions but not everybody actually connects with them and certainly people don't connect with them on the level where they give them respect right emotions are kind of this thing to many people me as well in the past that were like an annoying it was like rain if they're negative yes it's an annoying thing that kind of gets in the way and every so it's a sunny day and you're like [ __ ] sweet thanks thanks guys um but never actually connected with them I was like but why is it raining what does it mean and how can I work with this in a bit of a different way and why is it sunny and do I want this to happen more and what are the things that I do that engender that yeah and by the way you also realize if it's sunny every single day and it never rains do you really appreciate the sun yeah I uh I I had dinner with a friend a little while ago who uh told me about a girl that he'd started dating and he's the super rational cognitive guy and she's like crazy just in her emotions uh both cultivated and natural disposition for both of them so they've both like become more of what they are in some way and he said it was like uh boxing a southpaw he was having sort of he was coming from his perspective and she was coming from her perspective but he asked he's like you know is someone who doesn't feel things the way that you do said what's it like she's like it's terrible and beautiful I like there it is like you just the gam the the spectrum of experiencing things is so much broader but I've been through a a a few strong emotions over the last few weeks and uh one of the things that it really made me think about is how little compassion so many people have especially on the internet like you know you see someone who has a public uh they fall flat on their face in one way or another or you know they do something silly or the story comes out about them or they have a public makeup or breakup or you know their ex partner gets with somebody new or whatever it might be and like the way that people talk about other humans is so dehumanizing it's like it's WWE or or a sitcom or something you're like you do understand that on the other side of what you see as like a narrative Arc someone else has told you that those actual humans [ __ ] feeling things like in the grips of a a state and yeah like a guy at 36 realizes that people feel feelings like shock but uh yeah that was that really it really sort of woke me up to was there something in particular that happened that you saw that that made you feel this or made you realize this not particularly just me me kind of being in this Arc and and really sort of sinking into stuff there wasn't I think the the Jonah Hill thing that happened about 6 months ago uh was one of these Jonah Hill actor had a girlfriend they broke up and the uh ex-girlfriend kind of released the messages online and it the argument largely centered around should she have released them was he in the wrong was she in the wrong and like it doesn't really matter about that bit what matters is the fact that both of these people were wildly hurting they were showing it in different ways and you know was he being mature was she being immature blah blah blah but like just the way that people comment on this stuff has no regard for the fact that there is a [ __ ] human on the other side of this or like you know another good example love him or hate him it doesn't matter Jordan Peterson a guy who went through hardcore benzo withdrawal for a year and a half and I like watch this unfold from basically a front row seat I wouldn't wish that on anyone I wouldn't wish that on anybody athesia flying to First we'll go to Serbia then we'll go to Russia then we'll oh my God just like in this endless endless torture and people just at the time making jokes about Michaela's attempt to try and fix her dad or or you know taking like who is this man to teach us about responsibility in the modern world when he's addicted to benzo and just [ __ ] awful jokes I just like it makes me think like how bad does your life have to be that this is the place that you get to that you speak about other people like that and I'm not I'm no saint I'm not like brimming with unbounded empathy for people I don't say things like that and it just really it really sort of recentered like a bit trying to think about a bit more Humanity as as best I can I guess one of the other guys that I've heard about Ray Pete has a a prescription or a piece of advice which is to take aspirin every day have you come across this is this something to do with blood thinning yep and how legit is taking aspirin 300 milligrams of aspirin every day or whatever it is oh I mean that's been a well understood uh uh therapeutic intervention for folks that are at high risk uh for cardiovascular disease I mean it's it's an interesting story because it's had um it's one of those things where the answer or the presumed answer has changed so many times so you know there was a day when anybody would take aspirin for cardiovascular disease prevention and then it turned into well just very high risk and then it was well just high risk nope it's just very high risk nope it should be everybody and it goes back and forth and back and forth and back and forth and what's abundantly clear is the following um anybody is going to have a reduction in risk for cardiovascular disease by taking an aspirin or typically gets a baby aspirin which is 81 Mig quarter of the dose but there's also a risk from taking a baby aspirin and the risk is if you fall and bang your head you have a greater increase in the risk of uh Hemorrhage subdural or epidural Hemorrhage and so the real question becomes who are the people whose risk of cardiovascular disease is high enough that the benefit they get is greater than the risk of the bad scenario not skateboarders yeah well and the good thing is look skateboarders also are young and they have big heads and their brains don't SOS around too much when they fall and hit their heads yeah right but once you start to talk about people in their 60s and 70s and 80s and the brain atrophies a bit all of a sudden you're at a far greater risk for a subdural or sheering you got room in the more room the brain to move interesting so one of my patients who is on a baby aspirin for the appropriate risks was skiing two weeks ago fall Hits his head no concussion up back skiing everything is totally hunky dory but he's got persistent headaches for two weeks CT scan shows small subdural hematomas let's stop the baby aspirin immediately and wait for that to get better and we're very lucky we don't need a neurosurgeon to to go in there and drain it so um even though you can buy aspirin over the counter uh it's not an entirely benign thing and it comes it has a lot of benefits and we put the appropriate patients on it uh for example another case would be patients with LP littlea elevations that's a type of lipid um that's hereditary pretty common one in 10 people have elevated levels of it maybe more and you know there the risk of uh thrombosis from the hypercoagulable state induced by LP little a is greater than the downside of the subdural hematoma risk which is small but not zero that's interesting and what's the baby some people say by the way that if aspirin were being developed today it never would be approved why these risks oh okay yeah so the mechanism of action is a aspirin inhibits platelet aggregation so what that what's that mean platelets are the type of cells in the blood that are partially responsible for clot formation okay yeah so so aspirin impairs that by Design or as a as a side effect that is its that is its effect yeah right well I I mean that's I mean it's an anti-inflammatory drug that does that yeah right okay and this is so actually I think its first indication was actually for pain yes I always think of it as a painkiller rather than as a something to make my blood flow more easily is there a risk of people bleeding out as well if they were to get some sort of like if you were a war fighter uh would you would taking aspirin cause your blood to bleed out more quickly yeah probably although that's probably something that is more driven by other clotting factors not the platelets so clot blood clotting is a really complex process that doesn't just involve platelets but also involves a whole bunch of clotting factors Factor two Factor seven all of these things and you'll typically see so hemophilia you've probably heard of this disease is is a genetic condition where one of those clotting factors is deficient and every one of these results in a slightly different type of bleeding Disorder so hemophiliacs contrary to popular belief are not at risk of like you know spontaneously bleeding all over the place but they will spontaneously bleed into a joint more easily uh I forget all the factors I I can't remember if it's like Factor five deficiencies they tend to get you know you'll tend to notice if they get dental work it tends to bleed a lot um flossing their teeth will even cause a lot of blood loss so not a lot of blood loss but relative to what you would expect so um it's I mean literally the last time I knew the ins and outs of all that I was studying for my med school board so that's how long it's that's there was a day when I knew every one of these things but uh aspirin works on platelets speaking of that I saw a tweet from Elon saying when seeking medical advice act ask your doctor but also ask an experienced nurse nurses are underrated you think nurses are underrated with regards to their Insight around health and stuff like that yeah for sure why um again it depends on the system but if you consider a hospital for example which is where you're going to most encounter a nurse um you know like if you think back to when I was in a hospital which was in residency um how much time was I actually seeing a patient uh who is awake so because I was a surgical resident we were obviously seeing patients a lot when they're when we're operating on them but when you talk about a patient postoperatively who's going to be in the hospital for a week I mean I might spend a grand total of 10 minutes per day with that patient and the nurse is with that patient for hours a day lit literally hours a day so a really good nurse and not all nurses are good just as not all doctors are good but a really good nurse which is presumably what he's effectively referring to here um you know understands things and sees things and recognizes patterns uh very well and I know that when I was a res anyone who was a good resident and I prided myself in trying to be a good resident um you would very quickly figure out which were the nurses who you always listen to when they sort of said there's something wrong with Mr so- and so over there and they might say it it might be this or they might say I don't know what it is but he is not acting normal and I tell you more often than not like something would go wrong and it's like yep you know what she's seen the pattern enough of his mentation status or the slight decrease in his urine output and you know lo and behold he's got a GI bleed and it's going to show up at 2:00 tonight I'm going to be sticking an NG tube down his throat and we're going to be running you know five units of blood in him on the way to the ngoc cath lab so um so yeah I think there's a lot of Truth to that because they're just front lines and that's yeah that's so interesting I don't even think about that it's crazy when you know there's so much uh it's a shame that there's a big nursing shortage in the US is that yes absolutely why is so it's being met by you know importing nurses from other countes right so we um you know we bring a lot of nurses in from other countries um but look I think it's a hard job and I think it's probably underpaid it's it's a hard physical job too like shift work who says any type of shift work is a health risk know whether you're a firefighter or a nurse or a doctor yeah so um I just you know yeah I think it's it's physically demanding um again you know it's all there's so many different types of nursing are very broad profession right so you know you can do things as an outpatient nurse an in inpatient you know surgical nurse medical nurse ICU nurse I mean it's there's so much different stuff going on but but it's not easy work and um and it obviously has a lot of emotional consequences as well right how did you deal with that um I mean it was hard I think uh I think the there were there were moments that CA that struck me out of nowhere meaning I didn't understand why in the moment I felt so attached I think there were probably three or four times during my 5 years of training when you know in a in a way that I couldn't I couldn't have predicted an hour earlier I just became completely overcame overcome with grief um as a patient died um and um I I again I don't I don't these aren't things we necessarily spoke about together so I don't I don't understand like was that something that everybody was experienc or was that just something I experienced but but there were there were a handful of times when I was really just absolutely devastated and it's not necessarily what you would expect it wasn't like oh this is a patient I've known for a year um I mean in one case it was a and I write about this one case in the book it was a it was a boy that I just happen to be the trauma chief that night when he came in from in a car accident so I didn't didn't know him right but but you know he died right there in the trauma Bay as I was trying to resuscitate him and I can't I've lost track of how many people have died in a trauma Bay when I'm taking care of them like that's I need scientific notation to remember that number it's huge but there was something about that boy on that night that was impossible for me to Fathom um so I'm not sure why I have a friend one of my best friends in the UK who uh became a a F1 F2 uh med student practicing uh during Co Oh I thought you meant F1 F2 Drive I was like no no no no I'm afraid not we would both of us would be Trackside if that was the case um and he told me the story during Co of a lady who came in and when she came in she was a little bit short of breath and whatever whatever she'd call 111 or which is kind of like the slightly less intense 999 in the UK got taken in and uh he saw her and she was a little bit short of breath then he saw her 30 minutes later and she was blue he saw her 30 minutes later when she was dead from when she'd come in the lady that he was talking to and that one really hit him as well and he didn't kind of the same as you he didn't know why he didn't know what it was but he's told me that story a couple of times and each time he tells me it's kind of Haunting to just think that you know from being someone sat in a Uber or an ambulance or something and then 60 minutes later you're gone it's fragile and uh it's a lot like the first death I saw which I I think I also write about this in the book when I was a med student I think it was my second year and uh it was a woman that came in short of breath and you know being the med student I was sort of okay go and talk to her like this is you know she's a little short of breath she's probably having an asthma attack um and what it turned out is she was having a pulmonary embolism and in the midst of sort of just sitting there talking with her she has a cardiac arrest and you know that turns into a full code which ultimately ends with me you know being brought in to do chest compressions uh and and ultimately she died and it was again I it's it's it's one of those things where I mean I had never seen a person die before and it's compounded by the fact that I had just spent 30 minutes talking to her yeah yeah this cont this deceleration of aliveness I'm sitting here and speaking with this woman for 30 minutes who then an hour later is dead um and I remember it was a Saturday night and I remember riding my bike back home from the Stanford Hospital Hospital which is on the north side of the campus to where I lived I lived you know on the south side of Palo Alto and I remember just driving my bike back it's like midnight on a Saturday and you know at the time I had a girlfriend who was an architect she lived in San Francisco and we never talked about there was she had this kind of like she was skeed out by medicine so it's like our relationship was not at all based in talking about my day job my you know my school um and I remember being very upset when I got home because I really needed to talk to someone she your girlfriend would be the likely person but I also knew it was like yeah she she's not the one who's going to hear this um but I remember that feeling very distinctly of how upset I was and not and and not feeling like there was someone to talk to about it what do people gloss over in outlive that you wish that they didn't what were the most unpopular important insights you're about to hit fure on the bestseller list what do you wish people paid more attention to in the book but they're not I mean I I have to be honest with you I first off I have been completely and totally Blown Away by the response to the book and part of it has been the the number of things people have come to me and said that they've changed either Chang their mind about or just changed their behavior about and I through those discussions there's nothing that stands out to me where people are you know I I I I really don't know I I think that the two things that are pleasantly uh noted are one is you know the the fact that there's three chapters on exercise I think was a deliberate decision just based on the volume of what I needed to say and I think people have taken that to heart you know I think people are saying wow I thought I yeah I understood that exercise mattered but I now have a a much clearer path for understanding not just how much it matters but how to think about it comprehensively and then I think look the final chapter of the book and the epilogue which were you know not they were not something that was necessarily going to end up in that book and I think if my publisher had had their way it wouldn't have ended up in the book but I but I actually think that there's a non-trivial subset of the population who've read the book who say that that's maybe the most important part of the book for them and that it's opened their eyes to to the same sort of exploration so look if it if if it does nothing else right if it doesn't change anything about the way you eat or sleep or exercise or think about heart disease or cancer or Alzheimer's disease but it ignites in you kind of a curiosity along some of the stuff we've been discussing well then it's worth it then you could just save the time and jump to the last chapter that's a win yeah let's say that you could only do 10 exercises for the rest of time it could be any machine Any modality you're talking just weight exercises straight cardio could be anything you can it can be swimming it can be cycling it can be being on a bosu ball it can be hanging therapy it can be anything but you only have 10 modalities and can we can can one of them accommodate multiple variants of it like would a split Squad allow you to do every form of a split squat no no no so a rear foot elevated is a dedicated correct those are the rules and you've got 10 what are you choosing on now the bike bicycle road bike yeah cool at just you can do different intensities on the bike that's allowed uh is that because you get the big variation where I get my it's where I do my zone 2 and my V2 Max so I'm going to get my full Suite there yep um boy do I want want to use up I mean for now I'm going to throw in Ruck and swim but I'm going to reserve the right to come back and say because that only leaves me seven on yeah in the gym what would be the justification for Rook um it's just a it's it's just so beautiful to be out there carrying weight around it's also the most social thing that I do so I love when my patients come into Austin and I can go for a Ruck with them so you know it's it's whereas I'm not going to go for a bike ride with somebody or swim with somebody and and and most people don't want to lift weights together what about the stimulus itself is there something specific to the ru is it to do with the fact that you're loading joints yeah no I think it's it's it's great to be loaded without over pounding the joints um and it's also great training for other activities I do like hunting where you're walking around and it's challenging and you got a pack on your back with a lot of weight in it swimming why swimming even if it does get kicked out yeah I think you know look it's something that's always been near and dear to my heart with my background and um I also think it's a great sport for life um and so it also is something you can really do well at multiple intensities so you can really kind of do easy easy peasy Zone to and you can do like the most crushing Soul burning interval um it's an amazing way to train your lower body doing kick sets till the point of like the burn the you know it's just it's just a it's a it's a beautiful whole body workout in a way that virtually nothing is maybe with the exception of rowing all right three um I'm going to go with a relatively new toy in my life which is a belt squat so I very recently like in the last four months got this new belt squat machine and I I I have to say it is the greatest hip hinging device ever and it's it's really nice because it's just you're not actually loading the spine at all so I'm able to load my body with as much weight as I would have ever been able to tolerate in a back squatter or deadlift without any of the axial loading um so I that's definitely on the list who makes the machine oh I want to give them a shout out cuz I'm so happy with them um and I don't have any affiliation with them I think it's called squat Max or something it's a guy plate loed yeah yeah it's a it's a it's a guy who's a former NFL player and I'm blanking on his name I apologize I wish I could give them a better job shouting it out hopefully you can link to it somewhere y um but I think it's called squat Max MD or something like that how comfortable is the belt I've found a mixed variety this one is exceptional and and i' tried a couple beforehand yeah it's I get bruised hips if I get you know you've got some you should come over and try mine yep all right cool I fantastic I adore the belt squat I'm someone with lower back injuries and also I learned this from Dr Mike isrel the um additional uh CNS strain that you get from axial loading which is specifically through the spine and to be like oh I just get to completely kill my legs I can bail out whenever I want I can go to failure as much as possible I can get someone else to de lo the bar or whatever the plates easily to do drop sets I can do all this stuff and you're telling me that I get to do it so I'm all in for that okay so there's four it's it's going to have to be some variant of a split squat because I really love single leg stuff too so it would either be um a traditional barbell lunge single leg just a walking lunge uh step back so yep or it might be a rear foot elevated split squat with dumbbells or kettle bells yeah I mean that's I'm and I'm gonna I'm going to talk to the governing body and see if they're going to let me count that as one exercise I'm GNA really push on the judges here okay all right uh I don't think so I'm sorry I'm afraid I'm afraid you're gonna have to make you're gonna have to make a call between the two all right it's going to be one of those two okay um again the advantage of those is is is obviously you know legendary across the board also you want some ax loading right you do still need to be able to to do that so so again here we're doing it with a much lighter weight if I'm doing if I have a bar on my back I'm not really going above 135 pounds when I do that exercise yeah um I love the uh walking lunges all reverse lunges with dumbbells because it just feels I'm so stable I don't feel like I'm going to fall over it's good for grip strength as well which is quite nice A little bit of sort of trap work so yeah okay so there's five you've got five them all yeah um I would do I would pick uh probably a dumbbell press like a bench yep dumbbell bench press yep yep um either a oh by the way if I do pull up I can do all grips right sure you can go chin up and pull up from that and neutral uh come on you really pushing the limits here the governing body is going to have to meet and give me three grips okay all right so be it all right we'll do a three grip pullup okay um the squat of the back yeah um how many is that I think you've got six so I think you've got four more do you ask everybody this question I and does everybody take this long yes okay you're the the pain and someone asked me on a Q&A and I took even longer than anyone so so I've asked Phil Heath I've asked some of the greatest bodybuilders of all time so everybody I don't think there's a single person that hasn't said dumbbell either bench press or incline bench press that's like the one she got threat everyone's a bro deep down you've got for more um good Lord I don't even know I mean I haven't even included any of the kind of re important moves that I do right like I'm going to that doesn't count right like if I'm doing DNS like Dynamic neuromuscular stabilization stuff where I'm doing like you know uh like a i i if you don't know this stuff the the positions won't mean anything but I'm going to say that doesn't count okay yeah okay um I would probably also do uh a tricep extension so an overhead tricep extension one of my favorites so you have to obviously get humoral exension and then a tricep extension on that tell you what's a really lovely variation that we've been playing with on our Saturday session is a floor skull crusher mhm with small plates and that is just so nice held like this no so on a w bar uh oh oh oh i s me yep yep yep yep but just going from the floor just cuz I I've always felt a bit strange bailing out when you're on a bench so always a bit like and if all that you need to do to bail out is just go to here and it hits the ground I've really been enjoying that but that I mean that's yep every guy ignores it's just push Downs everything is push Downs or close grip bench it's like dude get your [ __ ] arms over your it's interesting I think the literature is pretty clear on this isn't there a significant difference in tricep activation when you have humoral extension correct yeah yeah so I I don't actually do anything that's not extended now one there may be a benefit to it but I obviously don't spend a lot of time doing arms is evidenced by my arms um thing that I did learn that was interesting like tricep kickbacks are kind of like they feel like a sh the shake weight of the upper body or something but that uh Jeff nippard talked about this the fact one of the heads of the tricep only gets activated when the uh elbow is behind the Torso y um so you can do this in a number of ways you could use a a cable and again put yourself into this position but that that actually is kind of important to get maximum contraction on it I like interesting yeah I never thought about that all right you not going to make the 10 for me that's fine that's okay so you got three more uh a hanging uh leg raise again probably at least 80% of people that have answered this have put that in as their R movement of choice yep are you going uh to hang I'm going arms in and then I'm going to do I get all three sides right that that counts as one movement don't even try to tell me that doesn't I have to say of all of the people I've asked this question to you are the most litigious needy by far the most [ __ ] litigious okay two [Music] more this is going to be a dumb one for most people but I probably do a farmers carry okay yeah I'll give you for this given that you're probably going to try and litigate your way through it I'll give you both unilateral and bilateral for that y um why um I think for me it's probably one of the best grip exercises as well and I like that um and I appreciate getting the unilateral for free um I'll tell you I would have accepted it even if I only could do it with a hex bar okay but that's my I like doing both but what I really love doing is I do this set once a week hexar loaded up pick it up 30 seconds of walking 30 seconds rest 20 times so it's a 20 minute set and you know I I would like to see people of our age should be able to do that with their body weight yes I've seen you talk and then obviously you know once you know you you keep progressing through that and you know I think I'm up to maybe I don't know I'm probably at 115% of my body weight now um so I think a you're you're really getting some grip strength there like you're really you know when you get into that 15th 16th set you're really feeling it um but also you're really you have to have a stable core to be able to do that you've got to be able to kind of control yourself you're you're you know you're you're getting great um uh dorsy flexion you know everything is so much harder when you're carrying that weight so I think it's a great exercise it's also one of the exercises I love doing as a it's a it's a great family exercise so believe it or not Drive see you swearing and sweating yeah the kids are doing it with me you know they carry their little weights and you know one kid's timing me and all that kind of stuff okay final one two more no one more I I feel like I'm just missing something so obvious it's almost like I need to see other people's choices is it bicep curs no I thought about that but it's like do you really waste one of your 10 on that that's true you've got pull same as car phases you've got You' got no direct shoulder work but if you're doing bench and then you've got your holds no you know what I'm going to take a seated calf phase seated Cal phase for the number 10 yeah for Solus why um first of all contrary to popular belief a seed cafr does still hit the Gast Rock so you are still strengthening the Achilles as well um and maybe maybe I would change that to a stand standing but I think the seated you can load so heavy and I really think that a strong Solus is a healthy lower leg I just think it's I think it's just a way of life um so yeah I'm going to bring that in at number 10 hell yeah Dr Peter here ladies and gentlemen Peter I really appreciate you thank you for joining me on the first ever one of these that we have done for the people that are just listening we've been cycling through a western landscape on a virtual video wall and then a a museum Atrium complete with moving dinosaurs uh for the last three and a half hours uh I really appreciate you mate I love your work I love the fact that you're diving so deep and making this stuff accessible to people what should everyone expect over the next few months coming out from you and your lab and the stuff that you're doing we've talked about a few of the things so I think I am excited about this sunscreen thing uh Sun melanoma sunscreen thing is an important one that we're going to do um we're introducing something new to our podcast which is going to be quarterly reviews so we get a lot of feedback hey Peter love your podcast can't keep up man three hours a week of super deep diving into stuff I need the tldr and yeah we have great show notes and all that other stuff but what I do and I think you do the same thing every time I finish a podcast I make notes so I use I have these Q cards these 8x5 Q cards and I write down the most important things I learned and I've been doing this forever and there's like a huge stack of these things sitting in my drawer that nobody's ever seen and so I kind of mentioned this to my team three months ago and they're like tell us what's on it so we had a call and I read them the last three month's Q cards and they were like dude that's a podcast that's an episode once a quarter you come and read your Q cards because it's what you found the most interesting and how did you change your behavior as a result of what you learned so we'll be introducing that in Q2 as well that's awesome uh where should people go they want to keep up to date with what you're doing I think our site is probably the best place petera MD or early medical.com hell yeah Peter I appreciate you thanks so much for having me