The Peter Attia Drive

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Alton Barron is an orthopedic surgeon specializing in the shoulder, elbow, and hand. In this episode, Alton breaks down the anatomy of the upper extremities and discusses the most common injuries associated with this area of the body. He explains in detail how he examines the shoulder, elbow, and hand to find the source of the pain and lays out the non-surgical and surgical treatment options as well as the factors that determine whether surgery is appropriate. Additionally, Alton describes the surgical procedures that, when done appropriately, can lead to tremendous reduction of pain and improvement in function.

We discuss:

• Alton's path to orthopedic surgery [3:45];
• Evolution of orthopedics and recent advances [8:45];
• Anatomy of the upper extremities [13:30];
• Rotator cuff injuries, shoulder joint dislocation, and more [21:15];
• Peter's shoulder problems [31:30];
• The structure of the biceps and common injuries [35:30];
• Labrum tears in the shoulder and natural loss of cartilage with usage and time [38:15];
• Shoulder evaluation with MRI vs. physical exam, diagnosing pain, and when to have surgery [41:30];
• How anatomical variation can predispose one to injury and how screening may help [50:30];
• Pain generators in the shoulder, and the important nuance of the physical exam [56:00];
• Frozen shoulder [1:05:15];
• Shoulder pain that originates in the neck [1:11:15];
• Surgical treatments for a labral tear, and factors that determine whether surgery is appropriate [1:16:00];
• Repairing the rotator cuff [1:29:15];
• Are platelet-rich plasma (PRP) injections or stem cells beneficial for healing tears? [1:38:15];
• Repair of an AC joint separation [1:45:15];
• Total shoulder replacement [1:55:45];
• The elbow: anatomy, pain points, common injuries, treatments, and more [2:05:30];
• How Tommy John surgery revolutionized Major League Baseball [2:17:15];
• History of hand surgery and the most significant advancements [2:22:15];
• The hand: anatomy, common injuries, and surgeries of the hand and wrist [2:29:30];
• Carpal tunnel syndrome [2:40:00];
• Other common injuries of the hand and forearm [2:47:15];
• Grip strength [2:55:15];
• Arthritis in the hands [2:59:30];
• Trigger finger [3:07:45];
• Nerve pain, numbness, and weakness in the upper limbs [3:14:00];
• The Musician Treatment Foundation [3:22:00];
• Gratitude and rucking [3:34:15]; and
• More.

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Gerald Shulman is a Professor of Medicine, Cellular & Molecular Physiology, and the Director of the Diabetes Research Center at Yale. His pioneering work on the use of advanced technologies to analyze metabolic flux within cells has greatly contributed to the understanding of insulin resistance and type 2 diabetes. In this episode, Gerald clarifies what insulin resistance means as it relates to the muscle and the liver, and the evolutionary reason for its existence. He goes into depth on mechanisms that lead to and resolve insulin resistance, like the role of diet, exercise, and pharmacological agents. As a bonus, Gerald concludes with insights into Metformin's mechanism of action and its suitability as a longevity agent.

We discuss:

• Gerald's background and interest in metabolism and insulin resistance (2:30);
• Insulin resistance as a root cause of chronic disease (6:30);
• How Gerald uses NMR to see inside cells (10:00);
• Defining and diagnosing insulin resistance and type 2 diabetes (17:15);
• The role of lipids in insulin resistance (29:15);
• Confirmation of glucose transport as the root problem in lipid-induced insulin resistance (38:15);
• The role of exercise in protecting against insulin resistance and fatty liver (48:00);
• Insulin resistance in the liver (1:05:00);
• The evolutionary explanation for insulin resistance—an important tool for surviving starvation (1:15:15);
• The critical role of gluconeogenesis, and how it's regulated by insulin (1:20:30);
• Inflammation and body fat as contributing factors to insulin resistance (1:30:15);
• Treatment approaches for fatty liver and insulin resistance, and an exciting new pharmacological approach (1:39:15);
• Metformin's mechanism of action and its suitability as a longevity agent (1:56:15); and
• More.

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In this "Ask Me Anything" (AMA) episode, Peter answers a wide variety of questions, starting with a discussion on the evolution of medicine and the hopeful transition to "Medicine 3.0." Peter recounts his unique career path and explains how he assesses risk and utilizes frameworks for decision-making. He also describes how he prioritizes his health while navigating the stresses of life, and he reviews the most exciting developments in the aging and longevity space. He finishes with some rapid-fire questions on cold plunging, strategies for lowering apoB levels, designing an exercise program for beginners, and more.

If you're not a subscriber and are listening on a podcast player, you'll only be able to hear a preview of the AMA. If you're a subscriber, you can now listen to this full episode on your private RSS feed or on our website at the AMA #41 show notes page. If you are not a subscriber, you can learn more about the subscriber benefits here.

We discuss:

• The evolution of medicine and the transition to "Medicine 3.0" [3:00];
• Peter's unorthodox career arc and what led him to this point [11:45];
• What does Peter consider to be his superpowers? [22:15];
• How Peter thinks about risk and explains it to his patients when making medical decisions [26:45];
• The advantage of using frameworks for decision-making [37:00];
• What advice would Peter give his 30-year old self? [42:15];
• Why longevity is such a hard problem to solve [42:30];
• The most impactful developments in the field of longevity and aging in the last 5 to 10 years [46:15];
• What is Peter most excited to see develop in the health and longevity space in the next few years? [51:30];
• Prioritizing healthy habits while navigating the stresses of life and time constraints [53:45];
• How Peter navigates periods of high stress [58:00];
• What fitness watch did Peter recently purchase? [1:03:45];
• Potential benefits of cold plunging [1:05:15];
• Advice for someone beginning an exercise program [1:07:30];
• Strategies and tactics to lower apoB levels [1:09:00];
• Interesting studies and books Peter has recently read [1:11:30]; and
• More.

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Erin Michos is an internationally-known leader in preventive cardiology and women's cardiovascular health. In this episode, Erin discusses current trends in cardiovascular disease (CVD) through the lens of female biology and the observation that major adverse cardiac events in both sexes are on the rise. She walks through risk factors including LDL-cholesterol, apoB, and Lp(a) and makes the case for the importance of early preventative measures. She explains various interventions for reducing risk including a discussion of statins, GLP-1 agonists, PCSK9-inhibitors, and drugs that lower Lp(a). She goes in-depth on female-specific factors that contribute to CVD risk such as pregnancy, grand multiparity (having five or more children), oral contraceptives, menopause, and polycystic ovary syndrome (PCOS). Additionally, she explains her approach with patients as it relates to the use of hormone replacement therapy and provides advice for people wanting to lower risk both through lifestyle changes and medications.

We discuss:

• Erin's background in preventive cardiology and women's health [2:30];
• Recent trends in cardiovascular disease in women, mortality data, and how it compares to cancer [5:15];
• Why early preventative measures are critical for cardiovascular disease risk [13:15];
• ApoB as a causal agent of CVD, and why high apoB levels are not being aggressively treated in most cases [19:45];
• The rising trend of metabolic syndrome and other factors contributing to the regression in progress of reducing cardiac events [27:00];
• GLP-1 agonists—Promising drugs for treating diabetes and obesity [33:30];
• Female-specific risk factors for ASCVD (pre- and post-menopause) [37:15];
• Polycystic ovary syndrome (PCOS): prevalence, etiology, and impact on metabolic health, lipids and fertility [47:00];
• The effect of grand multiparity (having 5+ children) on cardiovascular disease risk for women [52:30];
• The impact of oral contraceptives on cardiovascular disease risk [55:00];
• The effect of pregnancy on lipids and other metabolic parameters [58:45];
• The undertreatment of women with familial hypercholesterolemia (FH) and how it increases lifetime risk of ASCVD [1:02:00];
• How concerns around statins have contributed to undertreatment, and whether women should stop statins during pregnancy [1:09:45];
• How Erin approaches the prescription of statins to patients [1:16:00];
• PCSK9 inhibitors and other non-statin drugs [1:21:15];
• Advice for the low- and high-risk individual [1:28:30];
• The impact of nutrition, stress, and lifestyle on lipids and CVD risk [1:31:00];
• Lp(a) as a risk enhancer for cardiovascular disease [1:41:15];
• The effect of menopause on cardiovascular disease risk [1:50:30];
• How Erin approaches decisions regarding hormone replacement therapy (HRT) for her patients [1:55:30];
• The urgent need for more data on women's health [2:03:30];
• Erin's goal of running a marathon in every state [2:09:45]; and
• More.

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In this special episode of The Drive, we have pulled together a variety of clips from previous podcasts about cardiovascular disease to help listeners understand this topic more deeply, as well as to identify previous episodes which may be of interest. In this episode, Peter highlights the importance of understanding cardiovascular disease and why early intervention is critical. He also provides a primer on lipoproteins and explains the fallacy of the terms "good cholesterol" and "bad cholesterol." Allan Sniderman discusses the metrics measured in routine blood work – along with the limitations of those standard panels – before explaining why apoB is a superior metric for determining risk. Additionally, Tom Dayspring explains the causal role of apoB in atherosclerotic cardiovascular disease (ASCVD) and the therapeutic goals for apoB concentration, and Peter explains how early and aggressive lowering of apoB could change the landscape of cardiovascular disease prevention.

We discuss:

• The importance of understanding atherosclerosis early in life [2:25]
• Defining ASCVD, its causes, and the role of cholesterol [8:00];
• Why early prevention of atherosclerosis is critical [13:45];
• Preventing atherosclerosis—two fatal flaws with the "10-Year Risk" approach [16:00];
• Intro to lipids and lipoproteins: why there is no "bad" or "good" cholesterol [23:00];
• Limitations of standard blood panels [35:45];
• How Mendelian randomization is bolstering the case for apoB as the superior metric for risk prediction [39:30];
• Therapeutic goals for apoB concentration [58:15];
• How early and aggressive lowering of apoB could change the course of ASCVD [1:10:45]; and
• More.

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Holly Baxter is an accredited practicing dietician (APD), competitive bodybuilder, fitness and nutrition educator, and coach. In this episode, Holly discusses her experience as an athlete and competitive bodybuilder. She also opens up about her struggles with mental health, her long battle with an eating disorder, and the important steps she's taken in her road to recovery. From there, she explains how she would design a nutrition and training program for a hypothetical female client wanting to improve her physique through the addition of lean muscle and loss of body fat. She explains reasonable expectations for gaining muscle and the value of a "reverse diet" for maintaining weight loss, and she shares her favorite exercises. She also talks through some female-specific training considerations such as programming, reps, volume, hormone replacement therapy, and more.

We discuss:

• Holly's background and passion for sports and nutrition [2:00];
• Holly's struggle with depression and an eating disorder [4:30];
• Reflecting on her eating disorder, body image, and a wake up call [18:15];
• Road to recovery: therapy, meditation, self-compassion, and a breakthrough [27:45];
• The effect of competitive bodybuilding on women [39:00];
• Holly's competition prep and how she guides her clients wanting to improve their physique [46:45];
• Training principles for muscle hypertrophy [57:00];
• Training advice for an inexperienced person wanting to build muscle [1:01:30];
• Training program for a hypothetical woman wanting to add lean muscle and lose body fat [1:04:15];
• Lower body lifts: Holly's approach to leg workouts with clients [1:14:00];
• Upper body exercises: Holly's approach with her clients [1:24:45];
• Importance of nutrition and protein during the muscle building phase [1:34:00];
• Changes to nutrition and training during a fat loss phase [1:40:30];
• A "reverse diet" after a cutting phase to help prevent weight gain [1:49:45];
• Female-specific training considerations: programming, reps, volume, sex hormones, and more [1:53:15];
• Holly's future in bodybuilding and helping struggling women [2:05:45];
• Looking forward: Holly's focus on longevity, bone mineral density, and wellness [2:08:15]; and
• More.

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In this "Ask Me Anything" (AMA) episode, Peter discusses the importance of understanding body composition and explains how to interpret the most important metrics revealed by a DEXA scan, such as lean muscle tissue mass, visceral adiposity tissue mass, bone mineral density, and more. He discusses common concerning trends in these metrics as well as strategies to address them. He goes through DEXA scan results of both male and female patient case studies and explains the prescribed intervention for each patient. Additionally, Peter answers numerous questions about dietary protein including how much we need, when we need it, and how intake should be divided throughout the day to optimize muscle protein synthesis. Finally, Peter provides his updated point of view on time-restricted feeding and fasting and how his personal approach and recommendations for patients has evolved.

If you're not a subscriber and are listening on a podcast player, you'll only be able to hear a preview of the AMA. If you're a subscriber, you can now listen to this full episode on your private RSS feed or on our website at the AMA #40 show notes page. If you are not a subscriber, you can learn more about the subscriber benefits here.

We discuss:

• Interpreting DEXA scans: important metrics, radiation levels, and more [2:15];
• DEXA metrics: Bone mineral density (BMD) [12:00];
• DEXA metrics: Visceral adipose tissue (VAT) [14:30];
• DEXA metrics on lean tissue: appendicular lean mass index (ALMI) and fat-free mass index (FFMI) [20:45];
• Concerning trends in BMD, VAT, & muscle mass revealed through DEXA scans [24:15];
• Muscle and lean tissue loss with age and how to overcome anabolic resistance [29:15];
• Female patient case studies: DEXA scan results and prescribed interventions [35:00];
• Male patient case studies: DEXA scan results and prescribed interventions [42:45];
• Protein consumption: recommended daily intake, Peter's personal approach, timing around workouts, and more [48:15];
• What to look for with protein supplements [53:15];
• Protein intake: optimal timing and how it should be divided throughout the day [55:30];
• Time-restricted feeding (TRF): Peter's updated perspective [57:45];
• Three strategies for reducing energy intake in over-nourished patients [1:03:15];
• Prolonged fasting: potential benefits and tradeoffs [1:07:15];
• A protein-supplemented version of time-restricted feeding (TRF) [1:09:30];
• Theories about time-restricted feeding (TRF) and its positive influence on sleep and circadian rhythm [1:12:00]; and
• More.

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Arthur Brooks is a social scientist, professor at Harvard University, a columnist for The Atlantic, and the bestselling author of From Strength to Strength. In this episode, Arthur explains how intelligence changes as we get older, and how to take advantage of this to maximize our happiness and success. He distills truths about the meaning of happiness and its three main components: enjoyment, satisfaction, and purpose. He goes into detail about many of the keys to a happy life, including the importance of cultivating virtuous relationships. On the flip side, Arthur warns of the dangers of social comparison, "success addition," and the four worldly idols—money, fame, power, and pleasure—that drive many of us. Additionally, Arthur provides examples of exercises that can guide one in the right direction, overcome fear, and cultivate habits that can lead to a happier life.

We discuss:

• Insights from Arthur's career as a professional French horn player [2:15];
• A radical shift away from music to a Ph.D. in quantitative policy [12:00];
• Personal experience with shifting intelligence: fluid vs. crystallized intelligence [16:45];
• An epiphany from a chance encounter on an airplane that shaped Arthur's thinking [22:00];
• The three main "macronutrients" of happiness [25:00];
• Exploring the "purpose" component of happiness [29:00];
• The importance of having a partner and true friendships [32:00];
• The makeup of a true friendship, and why men tend to struggle with making real friends [36:45];
• The "satisfaction" component of happiness and the importance of "wants management" [42:15];
• The tyranny of social comparison [47:45];
• Insights into happiness through Chinese art, and the concept of a "reverse bucket list" [51:45];
• An exercise demonstrating the importance of relationships with others and the need to work on them [55:30];
• The four main idols that drive us: money, fame, power, and pleasure [1:01:15];
• Success addiction, workaholism, and their detriment to happiness [1:04:00];
• A radical approach to overcome fear—the antithesis to love and happiness [1:14:00];
• Ancient Hindu advice for the perfect life [1:26:30];
• The end result of getting caught in the 4 idols [1:31:45];
• The complexity of happiness [1:33:30]; and
• More.

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Michael Easter is the author of the bestseller, The Comfort Crisis. He's also a journalist, Professor of Journalism at UNLV, and a leading voice on how humans can integrate modern science and evolutionary wisdom for improved health, meaning, and performance in life and at work. In this episode, Michael first talks about his upbringing, including his parents' struggle with alcoholism, his father leaving when he was young, and how these things impacted Michael's own struggle with alcoholism. He explains what led to his realization that we are in a "crisis of comfort" and how the removal of many of life's discomforts through advancements in modern society may actually be a leading contributor to many of our most urgent physical and mental health issues. He explains the benefits of challenging oneself and the immense positive carryover which can come from doing things we find difficult. He describes the consequences of technology like smartphones, which have effectively eliminated boredom—a discomfort that comes with many benefits. He tells the story of a profound experience at an elk hunt that changed Michael's thoughts around life and death, how happiness can thrive in places without all of the modern comforts of the West, and why we're hardwired for stress and what to do about it. They conclude with a conversation around rucking, an activity with many physical and mental benefits.

We discuss:

• The value in doing something difficult [2:30];
• Michael's upbringing with a single parent and alcoholism [5:45];
• Michael's battle with alcoholism and his experience with quitting drinking [10:00];
• Origin of the idea that we are in a crisis of comfort [20:30];
• The death of boredom in modern society [28:45];
• The benefits of boredom [36:00];
• The value of disconnecting and being in nature [39:15];
• Changing the dynamic of how we think about food and the story of Peter's daughter's first hunt [43:45];
• How a profound experience at an elk hunt changed Michael's thoughts about life and death [49:15];
• How happiness can thrive in places without all of the modern comforts of the West [57:15];
• Why we're hardwired for stress, and the responsibility that comes with our level of comfort [1:05:30];
• How perspective on the timescale of our lives in relation to history can impart positive changes [1:14:00];
• The benefit of challenging oneself and the positive carryover it can have [1:19:45];
• The many benefits of rucking [1:28:45];
• Tips for rucking: ideal load, type of pack, and other considerations [1:38:00];
• Parting thoughts on the downside of comfort and benefits of difficult things [1:43:00]; and
• More.

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Don Layman is a Professor of Food Science and Human Nutrition at the University of Illinois Urbana-Champaign. He has spent the past 40 years investigating the role of dietary protein in muscle protein synthesis. In this episode, Don describes how his decades of research have shaped his thinking around protein, muscle, anabolic factors, metabolism, and more. He explains the recommended dietary allowance (RDA) for protein: what it is, how it came about, and how it should serve only as a guide for the minimum protein necessary for survival rather than as an optimal level of protein intake. He provides an overview of the essential amino acids, explains the nuances of animal versus plant protein, and provides insights for determining protein quality, absorption rates, and how to best track your intake. He discusses the ideal timing of protein intake in relation to resistance exercise, how protein should be distributed among meals, and how limitations in protein utilization per sitting can impact those practicing time-restricted eating. Additionally, Don shares results from his clinical trials, including how a high-protein diet fared in terms of fat loss, and explains the differences in protein utilization between adolescents and adults and how the problem of reduced efficiency of protein utilization in older adults can be overcome.

We discuss:

• Don's background: from growing up on a farm to studying nutritional biochemistry [2:30];
• Don's philosophy on nutrition, muscle, and metabolism [6:30];
• The controversial relationship between saturated fat and atherosclerosis [18:15];
• The basics of protein and amino acids [25:45];
• Origin and limitations of the current recommended dietary allowance (RDA) for protein intake [32:15];
• Protein sources: determining quality, absorption rates, and how to track intake [41:15];
• Leucine, lysine, and methionine: three important essential amino acids [48:00];
• The vital role of ruminant animals in the production of quality protein [53:15];
• The differing needs and impacts of dietary protein for a 16-year old compared to a 65-year old [59:30];
• Consequences of protein deficiency in childhood [1:06:30];
• Muscle protein synthesis: ideal timing, small meals vs. big meals, and more [1:12:45];
• Protein needs of children [1:19:45];
• How important is timing protein intake around training? [1:24:15];
• The role of leucine in fatty acid oxidation by muscle [1:28:15];
• High protein diets for fat loss: Results from Don's clinical trials [1:31:30];
• Influence of industry funding on nutrition studies [1:43:45];
• Don's thoughts on plant-based and synthetic "meats" [1:48:45];
• Problems with epidemiological studies of dietary protein [1:56:30];
• More.

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