The Rich Roll podcast
when it comes to life span. There really are four big elephants in the room. The first is atherosclerosis more people are going to die from cardiovascular disease than anything else. Cancer is number two, then you get into neurodegenerative diseases and a lot of this Roots back to
To metabolic health. I forgot that one, right? Yeah, it's almost the easiest one to forget because directly, it doesn't actually account for the loss of many lives. But once you have type 2 diabetes, your risk of those other diseases. Doubles
today, my guest is dr. Peter a TIA, he's a former
cancer surgeon and researcher who got his MD from Stanford. He is one of my go to doctors, I'm say the go to doctor from a for anything performance or longevity related. I think exercise is the single most important longevity drug. We have
Have Bar. None, Peter is both a Visionary as well as a world renowned physician who has dedicated his life to understanding the science of human health and the Art of Living a longer more fulfilling life. I got a couple more things. I would very much like to mention before we dig into this one but first
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The occasion for Peters return to the show is the publication of his brand new book out live, the science, and art of longevity and Peter's basic thesis is that aging and Longevity are just far more malleable than we think. And with the right road map, we all have the power to plot, a different path for our lives. One that lets us outlive our genes to make each decade better than the one before. And Peter has generously offered up 10 signed copies of this groundbreaking
Book for us to give away. So if you would like to enter to win a free copy, go to Rich world.com. Subscribe join our mailing list if you're not already subscribed then look for an email on or around, April 3rd with further instructions. In today's conversation, we offer a short overview of all of the subjects covered in the book. But in large part this discourse centers around the books Final Chapter which tells the story of Peters emotional health during a dark time and hi.
Highlights the critical and generally underappreciated role that emotional well-being plays in The Quest for a longer healthier life. So without further Ado, this is me and dr. Peter a TIA,
Well Peter, it's great to see you. Thank you for coming back to do the show. I've been looking forward to this for a very long time. I woke up this morning to an interesting text from you about the loss of voice and saw your Instagram videos. So first and foremost like how are you feeling? Are you even like up for doing this? Yeah I actually feel fine. I just sound worse than I feel but thank you for agreeing to still sit down. Yeah of course you sound a lot better than you did in the video earlier and
And you know, before we even get into anything, I think it's curious and interesting that you spent, what did you say? Like seven hours on calls and zooms yesterday. Yeah, and that is not unrelated to the final chapter of your book and, you know, your podcast is called the drive, you are somebody with a tremendous amount of drive. And so, perhaps deep down, there's still the Superhuman complex or the workaholism gnawing away at the back of your brain.
I suspect. So I suspect that and something probably you can relate to with your own past, but I don't think addicts ever fully recover. I think they get into recovery but I will probably always struggle with workaholism perfectionism, and those things, you and me both, there's lots to lots of to untangle their and that's, you know, perhaps where I want to spend a good amount of today's episode. But before we even discuss that I did put out, Arie, posted your
Video and put up a little pole and said you know is Peter gonna be able to do the show today. Answer a yes Peter always finds a way B. There's no possible way 74% believe in you. So we'll roll the dice and see how this goes. And I just want to say that the risk of a sort of self indulgent monologue at the top here. Forgive me for being a little bit long-winded, but just to kind of set the stage as I'm reading out live over the past couple weeks.
To prepare for today, which I adore this book. It's a great care of us and congratulations on finishing it. I think it's going to help a lot of people but in the in my in my kind of semi-unconscious I have a lot of things forming around in the back of my mind. As you know, my swim coach from Stanford skip Kenny recently passed away. We had a little discussion about that prior to that dick joachim's, who was my coach, exactly. Right. We'll skip skip a 79. He
He died, you know, the cause of death had to do with, I guess a hip surgery that he couldn't quite recover from but he did have Alzheimer's just the other day. I had an athlete in here called Timothy O'Donnell. I don't know, him course that he, you know, at age, 40 suffered, a Widowmaker in the middle of competing and in a half Ironman survived finished the race remarkably, but that was a very interesting discussion about, you know, the nature of heart disease and
And the kind of strangeness of being such an elite athlete, you know, you would think somebody like that would be immune from suffering from something like that, so that sense of mortality is kind of percolating in my Consciousness, and next week, I'm going to New York City. My dad is having a heart procedure, a valve replacement. After two failed attempts at this. My mother is suffering from dementia. My grandfather died, who was a champion, swimmer died at 54 suddenly from heart.
Like I'm 56, as you know, I've got these back issues which you've been very helpful with thank you. But my point being that that mortality is very much top of mind for me, you know, healthspan, what's truly important. You know, it's kind of really front and center for me in a way that it hasn't been previously, kind of just, you know, very present with that. So, I'm really grateful to have you here today to, you know, walk us through the nuts and bolts of healthspan extension.
In a really you know, grounded way you know, as I said I think this book is really important for so many reasons and not the least of which the vulnerability that you that you bring to your own experience and journey with the science in your own lived experience. So thank you for that. And, and, and again, you know, you go through all of these sort of pillars of Health span, the objective strategy, the tactics Etc. And, and the concluding chapter,
After is all about emotional intelligence, which probably people are going to find somewhat surprising, but I found to be revelatory. I sort of think you've buried the lead. I might have put that chapter first. I understand why she could lie embedded in there were two views on this Rich, you know? The when I wrote the book that the the editor felt that that shouldn't be in the book. Felt that, you know, that could be another book if you want, but that doesn't belong here. Yeah, and then conversely, I had a close friend.
And Hugh Jackman read the book. He was one of the only people who did and he said the same thing you did. He said this, is the opening chapter, not the end. It's so there was a tension between those two views. I didn't really know where I stood. And in the end, I think the negotiated truce was, it'll be the last chapter, but I'd be in this book because I don't want to write another book. Yeah. Well for anybody watching or listening, you know, please don't get two-thirds of the way through the book and not complete. It would be my message to everyone and it is
A sort of precursor to getting into that. I do think we should, you know, create some context here and Define some terms and you know, perhaps let's start, I do. Well let me say this, we did a fantastic podcast. Our first podcast, I don't want to be duplicative of that and also I know that you're doing a couple other podcasts and each host has their own kind of thing that they're going to be diving into I feel sort of somewhat uniquely qualified to focus on the emotional health aspect of it, but we should just canvas
You know, this a little bit so we understand what we're talking about. So first, let's just start with like how you got interested in this field to begin with, you mean, the field of longevity? Yes. Yeah, I mean, it really, I think started when my daughter was born. I think that just crystallized in me, a shift from the focus on performance, where, you know, the time swimming was my life prior to that cycling and all other sports but I don't know. There was just something about it, which I
It sounds really cheesy. I think but just holding that baby. I was like, then I didn't even really want. If I'm going to be brutally honest to be. My wife knows this. I, she really wanted to have a kid and I was in different. I thought it would kind of could stay out, you know, cramp, our style a bit but my indifference and her desire led to us having a child. And then, even the whole time, my wife was pregnant. I have jokingly said, I don't think I could like this kid as much as I love our cat because we had this cat that I really loved and my wife just rolled her eyes. And then of course,
The second, she's born like literally. There are genes that just start transcribing and I just look at this little ball of nothingness and I think, oh, my God, like I'm obsessed with her, and that, yeah, that was my first inkling to think about mortality, right? That was the first time I thought about.
I want this moment to last forever even though it won't with this child, but maybe one day, I'll have a grandchild. Don't experience this again. But you know, my training in medicine had nothing to do with this and frankly, I don't think anybody's does. I mean that's part of the problem. I think, as I talk about the book with this notion of medicine 2.0, right medicine has come a long way in 150 years and it's done amazing things but it's a little bit of the what got you here. Won't get you there. So, in some ways I think,
If I have one gift it's that I can usually identify people who are really smart and somehow convince them to Mentor me. And that's sort of what I've spent the last 12 to 14 years doing is just figuring out who the best people are in exercise science in lipid ecology and oncology and endocrinology and, you know, just learning from them. I mean, and sometimes that would mean like literally flying out to be in a clinic with them for a month and just seeing as many patients as possible.
And seeing what they're reading and trying to understand it and then kind of cobbling together a thesis around what this means. And in some ways I think the book is kind of the culmination of the thought process and it's much neater today than it was when I started the book almost seven years ago. Well, the background hum here to add, like a layer of nuance is one of you commencing this journey from a perspective from an engineer's mind, like,
An engineering problem, right? I'm going to solve and, and your background is in mathematics, on some level, you're a Quant guy. Like I could see a parallel universe where you're like a hedge fund guy, and he character and billions or something like that. Like that's kind of the cloth from which your cut. You have this early career in medicine, you go into Consulting, you return to medicine with a kind of renewed Focus or, you know, interest in this particular field with this idea of medicine 3.
.0, you know, an evolution of the way we practice medicine from a kind of diagnose, and prescribe perspective, into one that's more focused on prevention avoidance. Delaying, you know, with a very specific focus on these four horsemen, right? Which are the four main Killers. If we could eradicate those delay, those Etc, we're all going to be extending our life span. So talk a little bit about those four horsemen, and why
This is kind of the the locus of the discussion. Yeah, when it comes to life span, there really are four big elephants in the room and there's really a fifth that I think warrants discussion but it factors so much into Health span that I usually talk about it more over there. The first is atherosclerosis and you've already talked about in personally, it doesn't get as much attention as I think it deserves and I think that's almost just because we're so used to it. I mean, everybody's heard the stats, it's the number one cause of death in men.
When it's the number one cause of death in women, the leading cause of death in the United States, its leading cause of death worldwide. Just no matter how you cut the data more, people are going to die from cardiovascular disease than anything else. Cancer is number two, pretty much consistently in the same boat, right? For men for women in the u.s. out of the US, then you get into neurodegenerative diseases and in some ways. I think these are kind of, some of the scariest. We certainly have the fewest treatments for them, and they run the Spectrum from dementia Alzheimer's disease, specifically, which is the most prevalent.
To Lewy Body dementia, which is kind of a hybrid between a movement disorders, like Parkinson's and a dementing disease like Alzheimer's and then of course, Parkinson's disease. And then you also have a whole bunch of dementias that are not Alzheimer's specific such as vascular dementia, frontotemporal, frontotemporal, dementia, things like that. But all of these things are kind of in some ways, shortening, our life. And in the case of the latter, also reducing the quality of our life, which then leads into this. Other idea that I think doesn't get enough attention in medicine 2.0, which is quality
E of life and it's such a glib term. You know, the medical definition of Health span is something to the to the tune of the time of life in which you are free of disability and disease, right? But like, you and I are just as free of disability and diseases, we were 30 years ago, but we're not the same guys. We were 30 years ago, there's much more to it than that. And also, that doesn't even capture the emotional health piece of it in my mind, which I think is even though it's only one seventeenth of this book.
In terms of, you know, content that simply reflects my expertise in it, not my belief in the importance of it. So we have these four horsemen and and the kind of premise here is these are the things that are disabling and and you know destroying lives more than anything else. The biggest barriers to longevity Health span extension and they take years to sort of, you know, grow and mature. And we have this period, this
Typical period, what you call marginal decades, right? Where we're in slow decline. As these disease has progressed to the point where they're typically diagnosed in a medicine, 2.0 Paradigm, and then treated with a battery of pharmaceuticals Etc. And and your thesis is, we need to replace these marginal decades with what you call bonus decades and this goes to. Now, I understand the graph that is the your podcast. I never knew what that graph. Was that your podcast icon your
Vic now, I understand that. And, and what was interesting in the book about you, maybe you can elaborate on this graph and what it means, but it's all about kind of pushing everything out, you know, a couple decades later. But behind that is, is this fact that when you, when you really look at the science, like we really haven't extended Health span at all in how long 50 years. Well,
Well, if you, if you even just talk a lifespan and you go back a hundred and twenty years on paper, we've doubled lifespan, right? It's gone from about 40 to about 80, but if you subtract out the top eight causes of infectious diseases, it hasn't budged at all. That's quite dispiriting, right? So one way to look at that, is the glass half full approach, is what? An amazing job. We've done figuring out a way to die of far.
Infectious diseases, right? And that's basically been on the back of two things, right? That's antibiotics and vaccines, we've eradicated things like smallpox and polio and things that were devastating. We now have antibiotics, right? There's a good chance you and I would be dead by now if we lived a hundred twenty years ago, just on the basis of some infection. So that's amazing. But, you know, it's sort of there's also, you know, that, you know, the expression of like when the tide goes out, you see who's not wearing those shorts, right? Well, it's kind of like the tide has gone out and we kind of realize. We'll wait a minute. Like, we're not wearing our shorts when it comes to these other diseases.
Eases we haven't really figured out a strategy. What worked for those diseases? What worked for acute care?
Doesn't work for chronic diseases. Where prevention is what matters? Now that word is so diluted. It almost has no meaning because of course everybody on the surface agrees with the prevention of course we should have prevention but I think what's missing is the time scale of prevention. You know when you talk about a person who has a heart attack at 50 that thing didn't start brewing when they were 40, certainly didn't start brewing, they were 45, I think was brewing when they were 20.
And if we'd acted when they were 20, they wouldn't have had a heart attack at 50, right? There's a graphic in the book of a young man who was in his twenties, right? Who died from an act of violence. But only three years older is that there's a yeah, like a scan of his LED and you can see the plaque buildup already, right? Which is not uncommon, probably the typical case, and the idea being that, yes, we are, you know, hard at work on these diseases that are very
Young age. And to the extent that we can catch these things sooner or develop better, you know, technology and protocols and and systems. That incentivize these types of testing, you know, tests and scans early on that. We could intervene at a point where we could actually, you know, circumvent them. Yeah, I think a big part of it just has to do with there's an inconsistency sometimes in medicine.
You know, causality is one of the most important things in the universe. Like this is, if you just think metaphysically, causality is such an important concept. And sometimes in medicine, it's very hard to establish.
But there are certainly cases where we know it to be true. So we know that smoking is causally related to cancer and because of that we have a very clear strategy for smoking cessation which means before you start smoking, going to tell you not to smoke. The second you smoke ring try to get you to stop smoking. We don't wait until you've been smoking for 20 years to say well you've now accumulated a lifetime risk exposure to smoking. We should do something about it. Some of the words I think when it comes
Um, to smoking, we have the idea, right? But when it comes to the factors that are driving say heart disease, we're completely bass-ackwards, right? We don't act until a person's risk, 10-year risk, typically is above 5% in, think about that. We wait until your 5-year risk. Your tenure was rather for major adverse cardiac event is 5% or more to say. Now, it's time to do something about your lipids, but if we know which lipids are causally related to this disease,
why wouldn't we act immediately? Why wouldn't we like, what is preventing that? I mean, I know that that, you know, if you do a blood panel and you have elevated numbers in problematic areas, unless those elevated numbers are Beyond a certain threshold, the typical response is going to be, it's not that big of a deal. Or there's nothing to see here. Yeah, which was certainly the response in my case when I was in my mid-30s and had a bad family history and even had a speck of calcium on a calcium score.
I think the simplest reason is you don't have the trial data, right? So it's very difficult to do clinical trials, obviously, and prevention, Trials of most difficult of them all because you have to wait the longest period of time for an outcome. So there's simply no scenario by which we're ever going to take a group of 40 year olds who are healthy, take half of them and do you know the placebo and for other half of them do at aggressive lipid management and see what happens over the next.
30 years it's an impossible trial right? But it's and at the same time it's not a binary thing. Like in smoking it's pretty clear, right? But as you kind of eloquently point out, when we get into nutrition it becomes you know, unbelievably complicated. You know, obviously you know a doctor May tell you you should start exercising or exercise more but beyond that there's no specificity to that. So you spend a lot of time talking about the different modalities of exercise, Etc.
So it you know, it becomes it's a Rubik's cube of you know to the 10th degree, right? Trying to figure out what the interventions and protocols should be on an individuated basis based upon, you know what you know about where a person is in the very early in dish of any one of these Horsemen. Yeah. And I think it just requires a bit more flexibility and we think that's another subtle part of what medicine 3.0 is, which is the try. Again, it's one of these things. The term.
Ian and preventative medicine has lost a lot of its meaning as has the term personalized medicine or Precision medicine, but on some level, what these things mean are
You have an individual, you will never have a clinical trial that tells you everything you need to know about that individual. It's simply impossible. Clinical trials, take a whole bunch of people there. All heterogeneous, it squishes down a result into an average. It spits out basically a homogeneous response and it says this is evidence-based or it's not
But within that trial, there are lots of different responses and we kind of have to understand what that looks like, because no one that I'm going to look at is the exact average of the input of the thousands of people that went into that trial. They're going to be one of those thousands of people. So we have to sort of figure out and triangulate. Like what does that look like? And what's the implication for them? And, of course, layer and other things, you know, you asked a question. Should we be aggressively, managing? Everybody's lipids early in life. It's also a question of risk appetite.
Come with side effects, right? I mean, to get the levels to get lipid levels where they need to be to basically take heart disease off the table. You have to do it. Pharmacologically there's no no change in nutrition. One can make no amount of exercise that's going to move the needle that much, but that comes with a risk as well. And so the you do it always becomes a question of that asymmetry of risk. And I just don't think that those are questions. That can be answered in a heterogeneous fashion, right? And and and in our internet age, that's a very unsatisfying answer, right?
Like we want to know like you know stake, your plant, your flag in some extreme position and you know, create a created audience around, you know, whatever it is that you're you know what, you know, waving that flag around and you can get a lot of attention and there might, you know, I'm sure there's kernels of Truth and all of those things but the truth is is much more complicated and and sort of masked than that which makes this difficult and I guess that that brings up you know, kind of a more meta.
And around the state of health span science in general. I mean, one of the things I appreciate about, appreciate about the book is that it's so grounded, you know, and you're not, you're not making any kind of crazy claims and, and I've become kind of accustomed to and, and somewhat annoyed by Logic to, yeah. Logic to, you know, what this healthspan conversation has become, which is about moonshots essentially, and it's fun to kind of cast your gaze into the future and imagine a world like in that movie Elysium where
people get into pods and it diagnoses you and cures you immediately and maybe in some, you know, at some point we'll who knows, we'll get there but it's certainly not where we're at right now and so conversations around, you know, I'm going to live to be 100 and 80 or 120 and do all these sorts of things are really not helpful. Right? And and and you your work is very much a departure from that narrative. I think people might go into this book expecting some something like that because that's kind of what the conversation.
Like right now. So what is your what is your take on? You know, what what that conversation you know is all about right now and and how does that differentiate from what you're trying to say? And do you know, I don't think they're mutually exclusive and going back to kind of what you said earlier. I mean, I do sort of think in a parallel universe. I could have imagined myself being kind of a quantity, a hedge fund and well given the name of a hedge fund. What are you supposed to be doing? You're supposed to be hedging. Everything is a hedge in life. You always have a contingency plan.
And I always say to the people who tell me, I don't need to exercise, I don't need to do this. I don't need to do that because I believe in you know cellular reprogramming is going to totally rescue me in 10 years I say if you're right, that's wonderful. If you're wrong, you won't have a chance to come back to today and undo the damage. So what's the downside and doing everything in your power to extract as much value as possible out of the current, you know?
Entry tools, like exercise nutrition sleep Etc. And if you show up in 10 years, the worst thing that's happened. If the moonshot, is there, is that you've wasted 10 years, taking care of yourself.
Contrast that with the alternative a symmetry, which is you screw around for the next 10 years, and there's no moon shot. Now, the worst thing that happens is you're on a very quick path to death, right? These are, these are completely asymmetric and I think that, I don't know, I think that that kind of thinking has just always been sort of a part of how I think about stuff. So, in some ways, I might be the least. Interesting, least sexy person in this space because I'm really just trying to think about it through the lens of what we know. And
Look, I mean, you know, it's funny you mention I was on seven Zoom, you know, seven hours is umm, yesterday well, to of it was talking to scientists about, you know, a particular technology around epigenetic reprogramming but in a much more nuanced way than gets discussed sort of in the in the in the Gen pop. So it's something I'm very interested in but, you know, and particular for example, like looking at reprogramming lymphocytes and T cells to extend immune function in the elderly because I would argue
That if you could fix one cell in the aging body, it might be the immune system because you're going after two diseases, right? You're going after all the Infectious causes of death which for you. And I are nothing but you know, actually by the time you get to 80 and up like pneumonia does start to play a role, but I think it would also have the biggest impact on cancer. You know why is cancer growing exponentially? As we age? It's probably two things, right? It's probably the accumulation of genetic damage that leads to mutations then results in cancer.
Cells. But I think it's equally that our immune system is weakening and therefore not fighting back the cancer. So, am I super excited about the idea that we could genetically reprogram through an epigenetic rewrite immune cells and fix that problem? Absolutely, if the does it happen in our lifetime, I have no idea right? But it certainly wouldn't prevent me from doing everything. I can to maximize my odds of sticking around long enough.
And and on the medicine 3.0, you know, idea of early intervention, some of the technology around early testing must excite you as well. Because if we, if we can develop Technologies to catch these things at their Inception, that's huge, right? And there does seem to be some progress in that realm. Yeah, I think I think with cancer. The unfortunate thing is that we are still relatively limited and treatments. So I'd say the most exciting thing that's happened.
Happened in cancer in the last 20 years. Certainly last 10 years has been immunotherapy. And there's been a kind of what I would call minor success in a major success. The minor success has been the use of adoptive cell therapy.
So that's when a patient has a tumor and let's say, you can't treat that tumor, with all the traditional means. So you can't cut it out. It's to disseminated not responding to chemotherapy radiation. Of course, is no longer of any value, but you can Harvest some of that tumor and within it you can find lymphocytes, you can find their own immune cells that know how to at least attack and kill the cancer but you don't have enough of them. You can expand those cancer cells outside the body plus or minus genetically, manipulating them, and put them back.
And and they can go. And if they're in sufficient enough numbers overcome the cancer that works in a small number of patients. Now the Holy Grail, there is why can't we make it work in everybody because in theory you can always find some lymphocytes in a patient's tumor that figured out how to get there and how to at least kill some of them and the main reason is they get exhausted when you expand them. So, it actually comes down to the Longevity, if you will of the T-cell. So let's bracket that is one.
Problem. That's interesting to solve second thing in oncology that's been really exciting as these things called checkpoint Inhibitors. I write about them briefly in the book. These are drugs, they basically take the brakes off the immune system. And so, if you have an immune system that happens to be primed to recognize the cancer, you can take the brakes off it and it'll go nuts. Now, the bad news is that most people's immune system doesn't recognize their cancer. Well, enough to be affected by that. The good news is, if you are in that camp. This works almost every time. Mmm, so those two things are huge, but collectively.
Lee. We're talking about a five to eight percent dent in cancer treatment. So,
All Things Considered over the past 50 years, that's amazing. There's been nothing. That's probably had a bigger impact, but where's the rest of the Delta going to come for the next decade for you and me and for my patients I think it's going to come from earlier and earlier detection because the one thing that is abundantly clear and I go through several examples in the book is that stage 4 stage? The fewer cancer cells you have in your body, the better, your body will have a shot at beating a cancer with even traditional treatments
So even if you're talking about garden-variety colon cancer, being treated with garden-variety chemotherapy when you have a billion cells in your body, your odds are way better than if you have 100 billion cells in your body because of the number of mutations and the number of chances that that cancer has to escape the chemotherapy. Once you have an enormous expansion, same is true with breast cancer. Me, that's where we have the best data on those. So liquid biopsies, which are probably what you're referring to our tests that now.
Hours to take a couple tubes of blood and look for something called cell-free DNA. So normally if we took a couple tubes of blood out of your arm and we're not looking at hard, we're going to see all your white blood cells, your red blood cells, glucose, potassium, all these sort of things, right? But if you use really, really, really fancy equipment and high throughput, screening, you will notice some DNA. That is not from the cells because most of what is in your blood is cells and then liquid rights plasma cells. But there's
Tiny, tiny, tiny, fractions, like tenth of a tenth of. A percent of fraction of DNA that is not from the cells in your blood and these new techniques can not only identify where they're from. Hey, this is DNA from a liver cell. This is literally DNA from, you know, your pancreas or your lung. They can also predict if there's cancer in that organ.
Based on the patterns of methylation on it and that could then prompt you to go and get a more thorough investigation, which means we're going to sort of hopefully figure these things out a lot sooner. These things are still in their infancy. We are using these types of scans or these types of blood tests in concert with early and, you know, pretty kind of high-tech MRI scans that are not sort of traditional scanners. And the good news is, yeah, we're going to catch things really early the bad news.
Is you're going to catch a lot of things that aren't cancer, so this gets into that natural tension of everything you do has a cost and usually the financial cost is the least of your worries. The bigger cost is I can be pretty sure that you don't have cancer, but in the process, I'm going to identify a few things that probably aren't cancer but warrant follow-up and that creates Stress and Anxiety. And that's a real cost, right? And and and this is something that you're doing with your patients in your practice but I'm imagining
Inning, you know, the the medicine 2.0 Paradigm. Let's for purposes of just an example, you know, 32 year old male listens to this and says, well, I'm going to go get checked out for everything now. I'm inspired by, you know, outlive and Peter's message, goes to his GP and says, I want to get tested do all this stuff. What is the response that that person is going to get? Like, are they going to run up against some kind of barrier?
That's going to prevent them from even, you know, being able to Avail themselves of this kind of testing probably. I mean I had my first colonoscopy at 40 which at the time was 10 years. Before any recommendation that recommendation from 50 has now been lowered to 45. Thankfully I still think it's too high. I really do believe. Everyone should have their first colonoscopy at 40, but when I had my first one, I had to fight like hell to get it. I was paying out of pocket, no insurance company, whatever, cover it. And so yeah, the beauty of you
Is what are you doing? And again, my view comes down to just risk an asymmetry, a good. Five percent of people who died of colon, cancer are diagnosed with a colon cancer that occurs, at her before the age of 40. That's not a huge number but it's not zero and colon cancer, is the third leading cause of cancer death. So my view is the upside is that I get to mitigate that risk. The downside is the cost because I'm paying out of pocket.
And the risk of the bowel prep and the risk of the procedure and the risk of the sedation I can quantify all those risks. I can quantify this risk and on my balance sheet, there's no comparison. And I mean, I think part of it is you you can say, well, Peter gosh, you know, you're equipped to do that because this is your profession and what I hope is that I'm armed and people to do the same sort of calculation because I think we do have to do that. And we have to be our own consumers of this stuff, right? But but we have this
You
know, monolith, that is the, you know, Healthcare System. And you know, it's Gestalt towards bankruptcy and the cost that are, you know, incurred from treating. All of these chronic ailments. You would think that there would be a financial incentive to front-load patients with these types of, you know, tests and early detection, scenarios to avoid those costs later down the line, but it's so entrenched, it feels like an impossible task to to, you know, kind of rewire this
The system and create better incentives. Yeah, it's as you probably know I grew up in Canada and Canada as a single-payer Health Care system and there's almost nothing about Canada's health care that I think is better than the US has as broken as the u.s. is is because the Canadian system is got more problems, but there are two things that Canada or a single-payer system does better. The first is it actually provides healthcare for all and that's we don't need to get into that discussion here, but it's a tragedy that the number one driver of personal bankruptcy in the United States.
Is healthcare related cost, that's unacceptable. So nobody should be without health care. But the second thing that a single-payer system does very well and this is get this gets to the heart of what you're asking about, rich.
Is the pair owns the risk for life. So there is an incentive to prevent right now. My health insurance is Edna two years ago. It was Blue, Cross, three years from now, it's going to be United. What incentive does Edna have today to care about spending a dollar on me when they are pretty much positive, they will not own my risk in 20 years when the chickens come to roofs, right? Like, that's the fundamental problem. It's the
Portability of risk. And I don't, I mean, I've thought about this problem so much but until you fix that problem, until there is true risk ownership between the patient and the payer and the provider and that is carried out over the course of your life. There is no incentive for them to carry any of that risk.
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Yeah, I don't know what the solution to this is, but it's not good. But I do have, you know, hope when I see people like yourself who have carved out, you know, a really successful practice outside of that Paradigm. And you know what, we're seeing with functional medicine, doctors, Etc. Like people finding different ways of practicing medicine that has a higher priority on the things that you're talking about. One of the interesting things when it comes to the Four Horsemen.
Is the overlapping nature of all of these things. And one thing you talk about in the book is we start, we tend to treat these things in isolation as separate things, right? Like but in a Venn diagram they're all overlapping in terms of what's driving them or causing them and a lot of this Roots back to metabolic Health, which I feel like is a new frontier that finally is getting the attention it deserves and it's something that you, you know, have been
Been steeped in for a long time. So explain a little bit about what metabolic health is and how it relates to, you know, the on sent the onset of these chronic illness. Yeah, I'm glad you brought it up because I kind of got distracted. When you first asked me about the four horsemen, I forgot that one, right? Yeah. It's almost the easiest one to forget because directly it doesn't actually account for the loss of many lives. So if you count up the graveyards with heart disease, cancer and neurodegenerative diseases, that's a lot of bodies. If you go and ask the question how many people died
Type 2, diabetes fatty liver disease, or insulin resistance. It's a relatively small number of bodies, but the direct contribution of those to the other three, Horsemen is enormous, because once you have type 2 diabetes, your risk of those other diseases doubles. So I think of them as a Continuum, I don't think of them as discrete diseases. Diabetes has a very clear diagnostic cut off when your hemoglobin A1c exceed, six point five percent which means that your estimated average blood glucose is now above
140 milligrams per deciliter. We put a label on you, your called type 2 diabetic. But what about when your average blood glucose is 130 milligrams per deciliter or 120 milligrams per deciliter? I mean this is a Continuum, right? So I think of it is what happens when your hyperinsulinemic first earliest signs of this insulin resistant then you're kind of get you. Usually the next thing you're going to start to see as fat accumulation in places where we're not supposed to store fat. So you know we were really well designed to store fat in our Sub-Q.
Makes, You Know, cover up the six pack, all that stuff that's totally fine place to have fat, but we were not designed to have fat around our organs inside our liver around, our heart, pancreas and kidneys. Those extra, you know, fat cell places fat does really bad things when it gets in there, it's very inflammatory and that might be, in fact, I wouldn't say might be, I would say it is the most underappreciated driver of residual risk and cardiovascular disease, meaning
Even once you fix smoking blood pressure and lipids, you can still have risk of heart disease just from those fat stores. And when we think about how many people are walking around with non-alcoholic fatty liver disease. So, as its name suggests, this is fat, accumulation in the liver that is not driven by alcohol, which was historically. The thing that we thought was driving fat in the liver and it was this is devastating both in terms of liver, pathology if left unchecked that will progress,
Us to something called Nash, which ultimately result in cirrhosis. This is probably the leading cause of liver transplantation today. And if not today, it certainly will be within a couple of years. So directly there's a huge pathology there, but indirectly. I think it's what it's doing to these other things is, you know, these other horsemen is is huge problem, I don't think we're aggressive enough in screening these things. I talked a lot about that and talk about how we could be much more Vigilant and catch these things earlier. And
The challenges, you know, in some ways, these are the hardest things to fix because it comes down a lot to exercise nutrition and sleep. You have to manage nutrient, you have to be exercising. I mean, there is simply no better Elixir for metabolic Health. Fuel partitioning glucose, disposal than being active. And if your sleep is dysregulated, it's almost impossible to overcome it with enough exercise and nutrition. How would one know if there?
Accumulating fat around their organs, the easiest way to get a quick glance is doing a dexa, scan and a good dexa, scanner can estimate what's called visceral, adipose, tissue or vat? We use Noma G that basically show the percentiles by age and sex, how much of that is acceptable? So, in our practice, any patient that is above the 20th percentile for visceral adipose tissue on a dexa, scan, it's a huge red flag.
Liver fat is also relatively easy to identify once it gets bad enough, it'll start to show up in your liver functions, sometimes a doctor will then say well look we should you know, go and do an ultrasound to take a look. If a person has liver fat, the treatment is usually to try to get them to lose weight. I think we could be a little bit more specific than that, but that's that's clearly the best first line. And in terms of metabolic Health in general, you mentioned, you know, elevated, blood glucose.
What would constitute type 2 diabetes and and perhaps a little bit of a, you know, a lower number indicating being pre-diabetic but there's a whole range of prevention that we're not looking at right now to disrupt that you know, train that's that's already been pulled out of the station. He had diabetes might be one of the worst examples of where we just wait too long. You know, we really you know we wait until you're at 6.5 before we really bring out the big guns.
And I also think in part it's because we're optimizing with a different set of tools, the majority of the treatment, the real treatment for diabetes is drugs. Like if we're going to be honest, right? I mean, we pay lip service to exercise and nutrition.
But I think most people understandably like and I don't want to be critical of the doctor right? The doctors got to see a patient every 12 minutes. If you're running a clinic and you're taking care of patients with type 2 diabetes, you've got 12 to 15 minutes with each patient in 12 to 15 minutes. Assuming you even understand enough about exercise physiology and nutrition are you going to have an impact or is it easier to change the prescription and adjust the multiple medications? We have that are very effective by the way.
At you know, curbing type 2 diabetes, not really reversing it but keeping it in check. So there's a structural problem that is just getting in the way of doing that and if you wanted to fix this, you would have to actually do something that reverses it. And I don't think the medications are doing that. I mean, I think you have to basically change their nutrition status change the exercise fix the sleep, right? Despite the pharmaceutical intervention for a lot of people, it's just a band.
They'd on top of the causality, right? And not looking at the causality, is not doing anybody any good. That's why I did. Actually, I'm glad you brought that up. It just comes back to this other issue of causality again, right? I mean I believe that and I know I'm not alone in believing, that's right. I don't think this is a, I don't think is a particularly controversial. Diabetes is a disease of energy imbalance, right? It's a carbohydrate disorder. It's a carbohydrate metabolism disorder, that results from overnutrition, but part of that over
Nutrition is exacerbated by a lack of insulin sensitivity. Again, you know, sort of a body is a miracle in some ways, right? So if I drew your blood sugar right now, if I checked blood sugar on you, and it was 100 milligrams per deciliter, that would be a perfectly normal level that signifies that you have about 5 grams of glucose in your entire circulatory system.
Five grams is not a lot, that's a good teaspoon of glucose, that's perfectly normal. If I drew your blood sugar and it was 200 milligrams per deciliter, you would be a type 2 diabetic. The implication is you have two teaspoons of glucose in your circulation. This is not a big difference. When you consider that your muscles can hold, 300 grams of glucose, your liver. 150 grams of glucose.
So think about this, you could easily get a person who is a diabetic with 10 grams of glucose in their bloodstream down to five. If all you could do is get their muscles to hold more and their liver to hold back a little bit because your livers, the one that's kind of percolating it out there. I mean this is a game of mm and it's not rocket science to tip the balance in your favor. If you take, and I hate the word, but if you take a holistic approach to the organ system, right? And and this
Big part of, you know, the interventions that you, that you pursue with, with your patients, but a lot of this begins with getting your patients to use, a continuous glucose monitor. We talked a little bit about this last time I think so. I don't want to go you know, to deep down this Rabbit Hole. It seems like at least on the internet. This is controversial which I don't really understand like any information. Should be good information as long as it's paired with a solid, you know, Foundation of understanding and education.
In around what these metrics mean. But certainly it provides a window into what's going on metabolically with the people that you're working with. And I've, you know, I've used one myself and it's been fascinating to see how my body responds to various foods and in particular and you go into this in the book, the impact of stress and sleep on on how your body metabolizes glucose. Yeah, absolutely. I mean, probably the only subset of patients that I would be very hesitant to use it continues.
Cause Monitor and would be someone with a history of an eating disorder where you just put any additional stressor around food to me. That would be probably a contraindication but you're right. It is, it's attracted a bit of a strange controversy from what I would describe. As you know, a crowd that that probably wants to view the lens, they view the world through, a very narrow lens of evidence-based medicine, which is, you know, if there is no evidence that a person without diabetes can improve their health with this thing, it should never be used.
There's something to there's something to be said for that, right? If we don't at least consider those things, then we'll be, you know, the Holden to nonsense all day long. But we have to remind ourselves. That the absence of evidence is not the evidence of absence. Again, goes with that. Say, so instead, in my mind, I Justified these things by saying the following look, there is no shortage of data that demonstrate for non-diabetics, that is to say for people whose hemoglobin A1c is below 6.5, it's unequivocal that lower blood.
Glucose is better than higher blood glucose even within the quote-unquote normal range. In terms of all-cause mortality,
That means if you have someone who's average blood glucose is 100 milligrams per deciliter healthy, you know, that's what would be a hemoglobin A1c of about 5.1 and someone who's, you know, blood average blood glucose is 120, milligrams per deciliter. Also clearly not a diabetic. That person would be about a 5. Point 6, 2 5 .7 hemoglobin A1c. The all-cause mortality difference is real. So those data of course are based on hemoglobin A1c and not CGM, but CGM is allowing you to measure the average blood glucose, which is
being imputed by the A1C. And therefore I don't think it's an enormous leap of logical Faith to say if the CGM can help you manage to a better blood glucose, there's potentially a better outcome there. Another criticism that I've heard is that well you could eat bacon all day and your blood glucose, right? When you re a gaming it, or when you gamification the whole thing, then it's all about like, lowering that that curve, which might drive. Some unhealthy, dietary choice and I think that's exciting. That's a
Valid point my my sort of response to that would be well by that metric. We should never use anything that could be gamed by that definition anything became very like. That would mean that body weight is a totally irrelevant metric which is not true because you could gain. If I said, the only thing that is going to determine the outcome of your life, is your body weight. You could pick up smoking tomorrow and you know you'd lose weight but nobody thinks you're improving your health. So you also have to be a rational actor to do
do this, right? You have to realize that. Yeah even if I just ate bacon every meal every day and my blood glucose went down, I'm probably not improving my health. So we have to be careful. We don't throw the baby out with the bathwater when we start to come up with silly examples of how people can engineer and, you know, Goof Off with the game, right? I opened this by saying we were going to go right into emotional health. But I'm glad that we've talked about the things that we have talked about. And, you know, before we launch into
That like, let's just say, within this strategy of avoiding preventing delaying minimizing The Four Horsemen you have these four tactics basically, which involve exercise, which your thesis being that, this is the most important driver of healthspan, extension of anything that you could do and lifespan and lifespan, you have nutrition. You have sleep. And then you have emotional intelligence. But in the one, I omit, by the way.
A just because it would have been another book is all of the medical management, you know, it's sort of like, right? That's what I thought was my. But there's nothing in this book about pharmacology supplements and that seems to be the thing that people want to talk about the most, right? Like what is the supplement then? A deviant and a man and like all that kind of stuff, right? Like this is not part of anything that you're. Yeah. There's like I mean I do talk about a couple of drugs talk about rapamycin. There's a whole chapter on that it out fast for Max. I didn't know that that whole story about Easter.
Yes, Uncle, am I talk about lipid-lowering drugs? I talk and that's about it. You're ripe. I don't really go deep into the other stuff. The initial plan was there was going to be an appendix in this book that was going to deal with, just the what I thought were the 20 most relevant drugs and supplements. As I started to write said appendix, I realized it was going to add 200 pages to the book because it couldn't do it. I couldn't do justice to each one of those
In under about 10 pages. And so that idea quickly got sort of shut out, right? So the good news is I write extensively about those topics elsewhere. I podcast about those topics elsewhere and I just felt that, you know, this was the most interesting stuff to be writing about because it was the stuff that was not getting enough attention elsewhere. This book almost never happened. Also, like in the epilogue, are there in the acknowledgements? He basically were like, I worked on this for a long time. I missed my deadline for a
Are the publisher back, you know? Like yeah I got this is Beverly. Why was this so difficult for you to complete? I think they're I think there were two forces. I think the first is, I don't know. Did you experience this when you were writing a book? I mean, as a perfectionist, did you just feel like I can't put this thing out there because it's not 100% a million times? Yes. So now, yeah, like, that's yeah, this goes in. Okay, good. Elaborate like, this is, we're getting into this stuff. I really want to talk about.
But yeah. So there was the it's not quite good enough yet, it's not quite good enough yet, it's not quite good enough yet. I think there was a much deeper problem going on, which is I was,
Early on by 2008. So I started the book in 2016-17 is kind of a blur. My life is falling apart. His book describes 18. I'm trying to pick up the pieces of it and by nineteen, I'm back to kind of writing. The publisher is furious at me, at this point. There's a different publisher by the way. So, I'm going is my current publisher. Ah, the other publisher. I won't name, but it's one of the other big five. They've kind of had it with me at this point, but at this time, I know I got her. I got her, I got
Just ignore this emotional health piece. I got to be able to write about this because it's such an important part of Health span and health span matters as much as life span. So on the one hand, I feel conflicted because I want to write about it. And on the other hand, I feel like I can't write about it because I don't have my act together or well enough. I wasn't well enough to write about. Yeah, comment on it, so
I was sort of spiraling out of control in early 2020 when basically the publisher just kind of shot me an ultimatum, I remember I was filming Limitless. Actually I was in Norway and some I was actually trying to fly back from Arisen like I remember this very well known as dark. Awful hotel in a place I'd never seen before because the flight got canceled and I got stranded in some small place and I get this really nasty email from the publisher very threatening if you don't deliver this thing by such and such a date. Like we're going to take action blah blah blah blah.
Wow. And I just, I just called my co and said, why are the money tomorrow? It tomorrow and tell them to fuck off. And so that was the end of that makes wasn't that long ago. Yeah, three years ago. Yeah. And then the book basically, I just said I don't want to make this anymore. I'm done with this and and then the events in 2020. Unfolded and fast forward too late. 2020, I I was talking to Michael Ovitz who's
His friend. And I don't know why it came up. I don't know why the manuscript came up this part. I don't remember. I think we were talking about his book which I had maybe just read, and I was like, Michael. I can't believe it took me this long to read your book. I loved it. Bubba, Bubba, Bubba. And he was like, send me, your send me the manuscript and I was like, oh, it's it's not that good and he's like, just send it to me anyway, so I did and he read it and then he's the one that said, no, no. You got to finish this then and he said, if you can get me something within he said, try to get me something with in like six weeks that I can send to.
To my friend. Did penguin? Hmm, and that's what kind of resurrected the whole surface, the whole thing. And, yeah, when you were here, the first time after we wrapped the podcast, you shared with me a little bit about, you know, your, your personal journey. I knew nothing about that, I had no idea. And then in reading this final chapter of the book, it's really powerful. You you, you know, you really laid it out with quite a bit of vulnerability. And I think it's really important and you
Nausea importance of this. Basically, the emotional health piece being like, the most important thing, because if you don't have your act together with this, what is the point in extending your house man? Like, what like, Esther perel says to you, like, we do, why do you want to live longer like when you're so miserable which sets in motion, you know, this journey towards recovery. So talk a little bit about what was going on with you leading up to this realization but I think they were really
Ali, two big things that were obviously related but temporally distinct so I think bye-bye 2016, 2017. You know, I was probably working
I mean I was working really hard. I was traveling constantly, my wife was pregnant with our third child. I was nowhere to be found. I mean my two kids that were at the time my daughter? My son didn't actually think I lived at home. They actually thought I lived in New York or San Francisco or where the hell else I was traveling, you know, had had offices in two different places and all this kind of stuff.
But I think it's worse than that, right? Like, I wish I could just say, oh, it's just that, I was like, a super hard-working. Father, who was like, just, you know, working, you know, working really hard to make a lot of money for his family. Now, I think it was also that I was getting more and more detached, you know, and more and more just sort of selfish. You know, I think naturally I'm a very selfish person and I think that selfishness was just growing and growing and growing. And, you know, the event that comes to a head that I write about is after our youngest son is born.
And in June of 2017, I barely make it home for his birth. I don't think I'm right about that but by I was in New York when my wife went into labor, she was annoyed that I even went to New York the week she was do but I was like, I don't worry, I'll make it back. Of course, I barely make it back.
So I get to the hospital, maybe an hour before he's born, and then two days later. I'm back on the road and about five weeks later. I'm in New York, a friend of mine from Boston, is in town. We're getting ready to go out and I get a call from her and she says, you know, our youngest son just had a cardiac arrest, I'm in the ambulance with him. We're heading to, you know, you see us tear a tease
He's an infant is 5 weeks old and he, you know, we still to this day, don't really know what happened. He probably just had some awful vasovagal insult, but, you know, by some miracle it happened happened during the day, the nanny saw him roll his eyes back and turned blue. And luckily, my wife is a nurse practitioner, you know, she done Critical Care her whole life, so just did CPR on him, like a, put him on the floor, you know, sternum compressions the whole thing, while the nanny, calls the paramedics for five minutes later there.
They're just as he's coming back and for reasons that, you know, I can finally say this without breaking down but for reasons, I'll never understand. I just didn't get on a plane to go home. I was just so detached, I literally just treat it like it was a patient. I was like, okay, call me when you get to the ICU.
and then, for the next, like, five days, I just did a check in with the doctors every day, and
I didn't drag myself home until 10 days later. Can it? 10 days later? He came home. Yeah, and it's just, it was, it was just so blind to what an asshole I had become. It's so hard. I mean, I don't know you that well, but it's hard to Fathom that you would make that choice. You know, understanding a little bit about you know what, you know, kind of your your makeup, you know I can I can see how this would come to be but it's you know, it it's
Hear that. But I think it's really courageous for you to admit that not just, you know, in a podcast but you know, in in the book as a, you know, a way of Illuminating like the depths of like, how far gone you were in terms of your emotional health at the time, it was very hard to write that it was
and honestly it's something I to this day. My wife's only read one chapter that book that's she hasn't read the book yet, you know, because not out yet. But I did ask her to read that chapter I wouldn't have written that chapter without her blessing because I know that that's something, my kids are going to read one day and like my son will read that one day and he's five today. But he's going to he's going to read that one day and know that his dad didn't come home and it's so funny. He he says, I don't know how he knows this, but he must have heard us saying this but he always says mommy saved me.
And lately he's been saying Daddy, did you save me too? And I say, no, I didn't Terry, I didn't save you. Mommy said you daddy wasn't there. Why weren't you there? Like, he's starting to ask these questions and so you're the Healer, this is your identity. Yeah, so there will be a reckoning for this. I mean there there will be a, there's no question. So as the summer of 2017, blood into the fall of 2017, I was spiraling out of control. Like, I mean, there's this
I don't know what was driving all of this but I mean I almost got into a fight in the parking lot with someone and and this is like, I mean this was more than just a shouting match like I was going to kill someone in a parking lot over nothing. Literally some guy left a note on my car, you know, a chirping noted in my car and I was like, oh, really? I've seen so around this time, Paul, Conte. Who, you know? Yeah, is one of my closest friends, we were. We met the first day of medical,
Ed school and immediately connected over our love for Ayrton Senna who my youngest is actually named after and Paul, and I shared an office in New York. So we saw each other all the time.
And he just said, I I think you need to go somewhere. I think you need to go somewhere for 4430, you know, for like residential care and I was just completely reluctant to do this. I mean, he talked about, you need to go into a truck. You know, this he was talking about this place called the bridge to recovery, which is for trauma. And I was like,
It's doesn't make any sense, dude. Like, what are you talking about? And he's like, because you got it, you got to trust me. Like, you live, like a trauma victim. Everything about you is a response to trauma and I don't know what it is, but, you know, he just basically said in a non condescending way, you kind of just got to trust me. And so, ultimately, I did go there. I went there at the end of 2017 for two weeks. Had anybody else told you that you would not have listened. That's correct, right. Yeah.
The stuff in the book about about the bridge from my perspective as somebody who's been in treatment. Yeah, I want to hear your thoughts pure comedy. Like just even you can see here, I fuck. Yeah, like hilarious, like your resistance just refusing to participate, you know, unable to share. Even the remotest, you know, kind of emotional response completely detached from, you know, any any any ability to connect with let alone articulate like,
What was going on inside of you is pretty funny. It's good stuff. And to the point where this goes on, I can't remember whether it was the first treatment center of the second one, where the other impatience are like a disguise serial killer, like, he's just sitting there silently, won't talk, like, what's going on with this guy? Yeah, I mean, at some point, they gave me a piece of paper that had all the different types of emotions and they were like, just see which one of these you are, like, I know you say it's, I anger.
Sure. But there must be something besides anger. Like, is it anger? Because of hurt, is it anger? Because of embarrassment, is it anger be like, they were really trying to help me expand my vocabulary because I sort of showed up as a monosyllabic idiot. Right? So, you know, the two weeks I spent at the bridge was absolutely, the beginning of the change, but I think incorrectly left after two weeks, and everybody sort of felt. I really needed to be there for at least six weeks, because it's really designed
As a bigger program, the first two weeks is really just to uncover. What the heck is going on, but you don't get handed any of the skills to go about fixing it. Mmm, so even when I came back I wasn't really in a position to kind of fix. Anything sure? Yeah, it's interesting. Like, you leave AMA, right? Like the patient, you know, the the smart doctor guy is a terrible patient, you're somebody who resides in your mind. You, you pride yourself on your intellect, you're a very smart guy.
Why these are people that you know, are very resistant to this type of help, right? Like I'm okay, I understand this intellectually. I get it. Like I'm going to now solve this problem with my brain, not understanding that, it is that brain, that created the problem to begin with and the journey towards recovery. Involves disentangling. All of that letting go and allowing people in to help you, but you're somebody who is, you know, basically fueled by self-will.
And your own sort of independent way of doing things outside of any external inputs. And you know the interesting thing is, I think when I left the bridge, I was definitely cracked open and I think I did great things. When I got out in terms of like, it's not like I didn't, you know, do therapy and Esther introduced me to a guy named Terry real. Who was amazing, but there was also certain things I missed that. I think you only get in residential care and one of the things was every night at the bridge, you went to a 12-step meeting in town.
And so, every single night, imagine that for 14 straight nights, you are at a 12-step meeting and they don't care. What's 12-step meeting, it is. So, I was doing a, a sa like, na didn't matter what? Yeah, what are you just like leaning back? Well, it's coming fast. I know. I initially, of course, I was initially, I was, like, why am I here? I don't even have my phone. What am I doing here? Like, but I'll tell you. By the time I started to crack open, I was
I was really moved by this and I remember when I got back to San Diego thinking, I wish I could go to a 12-step meeting even though I'm not an alcoholic, like I want to listen to what they're saying. Like, I want to hear that there's someone else, who's struggling with something, and I think that was a missed opportunity. Yeah, so a seed is planted, you've got Paul, you've got some introduction to the notion that trauma plays a role, you are resistant to the idea of being an addict in any way. Like I'm not an addict like I. Yeah, I almost got in a fight.
And like yeah I realized like I work too hard and I'm not present with my family but does that really put me in the category of these other people like you're struggling with your ability to connect and relate to you know what is being presented to you? I think I started to fix. I did I guess it was probably about the summer of 2018, I really did. Start to make some really big improvements with my my life and I really started.
To heal.
From from all of that, that hurt. Now, I was still working way too hard was still traveling like a dog.
And I don't write about this in the book, but this goes on for another year. Until November of 2019, I have
probably the closest I've ever had to a nervous breakdown at the time. It was actually an Austin. So this is my still live in San Diego. You know? Every year I go out to watch Formula One and so sure enough. I go out to Austin to see Coda and I had an amazing lead up to it hosted, a bunch of podcast. There were some people I wanted to interview their the night, the morning of the race I wake up.
And I just have a total anxiety attack, which I've never had in my life and I decided I can't go to the race.
So I just call an Uber go to the airport and go home. I missed the race and I get home and my wife thinks it's really weird and she assumes its well, maybe he's just feeling like really burnt out and just needs to be with us more. But something was definitely broken and the next day, we had our team was in town. We're supposed to be making a bunch of content videos. And I just completely flipped out. I was at the Whiteboard, literally, trying to make the first one and I made a mistake and I flipped out like, I was like, I'm done. I'm done, we're done like this.
All things over. This was 20, 20, 20, 19. Oh, this is, this is before the stuff you talk about in the book. Okay. Wow. And, and then I spiraled into a very deep hole of like,
I mean, very significant thoughts of self-harm very
very desperate so bad that Paul actually flew down to San Diego and we holed up in a hotel for a day and Paul's diagnosis that time was crystal clear, which is
You, you are so angry at yourself for how much you punish yourself that you're kind of turning your anger inward. Now, at the guy who's been whipping you, like there's a guy inside who whips you and you are now so angry at him that you want to hurt him and he's like you have got to stop this and I was like okay okay I'll start taking you know and I again I just did this stupid thing of like I'll do a little bit less, I'll do a little bit less. I'll do a little bit less.
And I limped along until I didn't.
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The elevators get on down. You got a couple opportunities to step off but you needed a little bit more paint. Yeah so 2020 it really all comes to a head. Yeah and I think I would have been able to limp along for another couple of years had it not been sort of the acute crisis of covid and and who knows maybe it? Maybe it would have happened regardless but but it all kind of came to a head one day in a really scary way. And it's really weird that we're talking about all this
Sigh. I just think people are going to, I still to this day when I talk about this stuff, well, I've never really talked about this publicly. So there's a part of me that worries that, you know, Society may I just not sure I want people to know about but it's one this particular Wednesday in April of 2020 started like any other day, right? So wake up and it wasn't like any other day because this was, you know, slightly nose during covid. So it was different hours. I was sort of schedule the day where I would do my work early early in the morning because we had an East Coast team. So we'd start
At 6:00 in the morning etcetera. A lot of my rituals are kind of gone. A lot of this sort of things I do for self-help or being thrown out the window. But I do always, you know, do something for pleasure before I work out. So, I'm either going to go and shoot my bow and arrow, or go and get in my simulator and drive, and then exercise and then, you know, by 10:00 and get back to work. So, I go out to shoot my bow and arrow, and I'm really shooting poorly. Now, archery is a pretty objective thing. Like there's x's and you're trying to hit them.
And I'm for me, I'm off and I am so pissed off.
That I take these carbon arrows and I start snapping them on my thigh.
Now these things leave welts on your legs that lasts for a week when you break them, that's how much it hurts and I couldn't stop breaking them on my leg, every one of them.
And then I decide in my Infinite, Wisdom, that the best thing I could do then is go and get in the simulator and drive, right? Because ramp this up another well because, you know, it's like look, I didn't get the self-validation doing this thing. I'm gonna go find another way to get self-validation. So I go and get in the simulator.
Get into the hardest car on the hardest circuit and sure enough I'm spinning just can't keep the car in control. Amazingly I don't break the simulator and I decide. Okay I'm going to go and work out and for the first time in my life I'm actually too upset to work out. Like I can't I don't have the motor control to lift weights. She's very it's just strikes me as an impossible
scenario
the rest of that morning. Spirals out of control but come
Emanates with me, absolutely losing my mind and taking a table in our living room and throwing it across the living room.
wow, at which point my wife comes running in thinking that the house has been broken into
And the rest of it is a bit of a blur her at first trying to console me. But then quickly, realizing it's way too dangerous to be near me.
and then just telling me to get out,
I ended up in a motel.
And didn't eat or drink anything for, I guess, three days.
I
was on the phone with Paul Esther Terry, convincing them that I was ready to go home and all of them saying absolutely not like if you go home we're going to call the police. Wow. Like there's only one thing that left for you to do you. You have to go to this place called PCS psychological Counseling Service which is this place in Phoenix.
And of course, I just fought with them for hours. I was like, I can't do it. I can't do it. And they're like, you're, you're missing the point, you're acting, like, I'm giving you a choice. Has, don't you know who? I think I am. And I'm so busy, and I have all these responsibilities, but I can't do it because I'm too scared to do it. I mean, obviously, there's probably a bit of both but, but it's all being it's all being here. I'll tell you what. The fear was rich. Truthfully, the fear was, I'm not fixable. So why are we fucking around with this, huh? And that's really the core of the whole thing.
Yeah, right. Like that's what that's what starts to get revealed. Like, what is behind this? This this this rage. What is the relationship between that rage and Trauma and your relationship not only with your past but but with yourself, right? Yeah. So I think this surface fear is it's impossible for me to go away for a week and they said it could be one, it could be two, it could be 3 that's going to be
I did buy them. Hmm, But I said even a week is impossible because I like, I can't go off the grid. Like, when you're at these places as I'm sure, you know, you don't have a phone. Sure you're not doing anything. Like you're in therapy, 13 hours a day. 7 days, a week group therapy, individual therapy. I mean it's the most exhausting thing you can do but you're absolutely right underneath. It was the deep and the much deeper fear which is
I'm that guy. I'm that guy who has to go into rehab every three years and never gets fixed.
Just euthanize me like why are we why are we doing this nonsense, right? And it seems like and correct me if I'm wrong. There's this this tension or dichotomy of kind of holding two contradictory perspectives on yourself. On the one hand, you know, I'm look at me, I'm so successful. I have all these responsibilities from the outside. Looking in. It appears that everything is together. And I know how to solve this better than anyone because
I'm me, right? And on the other hand on the worst piece of shit in the world, I should just die. I am broken. It's a reparable. Like, who cares? Why even try and and, and you're absolutely correct. And then on top of that, there's the shame of God forbid. Anybody actually think I'm special if they could only see how horrible I am, right? Right. And the fear that at least publicly, anyone would know that you're that, you have some fellow ability.
Especially so deep. Right? It's one thing to be like, oh, I eat too much chocolate or something like that. But this is this, this this to me was like, are rotten to the core of like, who I was right. This was this was not just a quirk of Personality or, you know, I struggled with smoking or something. None of this struck me as like a fundamental like this was the to me, the lowest possible, you know, set of character traits one could have which also creates the best.
Place to begin this kind of work. Right? Like that that you know you hit bottom. Yeah. So hopefully, that creates a space of willingness to entertain a new way. Yes, it's sad to say, I had to hit rock bottom and of
course,
you know, here we are three years later, my life was completely different.
In always infinitely better people. You know, sometimes people say to me it's a question, you think you can ask anybody, right? Like if you go back and talk to the 20-year old version of you, what would you tell them? What would you do? Different
On the one hand, I wish I could say figure this stuff out. 30 here sooner buddy. Like you're going to save everybody including yourself, but more importantly people you love. You're going to save them. So much pain. On the other hand I think I don't know if I could have figured this out unless I was on the bottom and the basement, right? Like I just I think at least for me I needed to be in so much pain to actually do this thing to go through this.
Stuff. I mean do you think about the same you and me both buddy? You know, I mean when you present emotional health as this core pillar in health span on the, on the kind of subject of early intervention, like all of this is about like how do we catch these things? Diagnose them, and start treating them way earlier, on than we historically have been doing the tricky thing with emotional health, is, it does require willingness so you could, you could, you know? If somebody came up to you, when you were 28 or 24
30 or whatever and tried to intervene and get you to understand that this is important. There's no way that you would have been game to, you know, dive into this right. So it's a lot more difficult but perhaps had that intervention occurred when you were eight years old or there were modalities in place to help you make sense of confusing things, you know in your in your childhood during that period of time. It could have created a different trajectory. Yeah you know for me the
That the sign that this was really, I was ready to go through. It was the most important thing I had to let. Go of was whatever changes I'm about to make will result in me being less effective in my professional life. That's the big one. Yeah, that's the big one and that gets to the root of your sense of self and the incident you know, workaholism that's a manifestation of that unhealthy sense of self like the facts of your experience. As they say in the parlance of recovery like the facts of your
It's a very different from mine, but the emotional landscape is so relatable to me, like, there's a lot of overlap. Like we, you know, manifested are disorders in different ways, but it's so similar to me in so many ways. And, and, and there is that thing of nurturing that dysfunction under the illusion, or the belief, that that is the the engine from which you've been able to create a pretty great life. And if you're to go and if you're, if you're
To dismantle that then What Becomes of you like you aren't going to be able to do the thing that you that you do that has distinguished you and and crafted this identity and sense of self. Yeah and all the success everything. Yeah and then the funny thing is
Maybe by some Metric, I'm less successful and less driven today than I would be had. I stayed on that path, but the opportunity cost of that was too great and I'm actually really comfortable with that. One of the things that I never thought could go away. I talked about this in the book is the whole Bobby Knight thing. This was one of the most important realizations I ever had when I was at PCS, which is what my inner monologue sounded like and it sounds, well, it's a little hard to believe.
I wasn't aware of it given that it wasn't just an inner monologue, it was actually also an outer monologue. I would constantly say things to myself out loud, whenever I made mistakes, the self-talk was not just in my head. It was it was verbal, it would come out and it was awful, right? It was
The reason I called that Bobby Knight is, that's that's who it was modeled after, right? It was coach, Knight is going to strangle you if you make a mistake and it was anything, right? It didn't matter. If I screwed up making dinner, if I screwed up a shot, if I screwed up anything, if I was late to a call, I remember one morning, I woke up and there was a call on my calendar at six that I had forgot about. And I, when I woke up, I did a whole bunch of other things before, and I missed the call me instead of just emailing the person saying, hey, I'm really sorry.
I mean I must have beat myself up about that for a day. Uh-huh. And this exercise that they had me do there was one of the most powerful things I've ever done and when they suggested it I thought
It seems kind of dumb like there's no way that's going to work and they were like every single day, two or three times something is going to happen. It's going to prompt you to want to scream at yourself. Take out your phone and record a message but look into the eyes of your best friend and pretend that they made that mistake. What would you say to them?
I mean the first two times I did this, I was in tears.
Because it was such a shift of how kind I would speak to that person, you know. Hey Peter, I know it's frustrating. You you just you know, didn't have a good drive today but you know, I think I think there's a lot on your mind today and you know you did okay. But, you know, you got to watch the Apex going into this corner and like I literally have like talking like I was a kind coach. Yeah. And there was an accountability where every one of those I would send to my therapist. So Katie Powell would get
Every one of those as a text message, should get like two or three of these voice messages a day for 4 months.
And it only took about four months for that to go away. That is really amazing to me. Yeah, that's powerful. Think of how old I am and think of how many years, I had this ingrained pattern of screaming at myself. And I mean, I don't even want to repeat the stuff I say because it's so vile. But like, it's not like you idiot. No, no. It's much harsher than that. And in just four months of being mindful of this every single day.
I don't even remember it's so hard for me to remember Bobby's voice. Hmm.
That's a a powerful Testament neuroplasticity that you could rewire that because that is so deeply ingrained that's something that, that I share this inability to extend compassion to myself. That is second nature to extend to another human being. I don't know if I don't think, you know this, but before Christmas, I, I went up and spent a week at Paul Conti's Clinic. No, I didn't mean some trauma work and, and
Family of origin work and it was revelatory for many, many reasons. Like, I'm just so grateful that I was able to have that experience. And I learned a ton. But, but perhaps the biggest Revelation that came out of that was this very thing of my inability to to exercise self compassion, like the negative self-talk. And the standard to which I hold myself is far beyond anything that I would expect.
Anybody else to the point of just, you know, utter cruelty and the extent to which this not only runs deep but infects like everything that I do to my detriment. So first just I mean, obviously, I've kind of always known this but like really trying to understand that and then, you know, creating that that lattice work to understand how that relates to Childhood trauma. And then beginning, the process of undoing it, like has been, you know, it's been extraordinary,
Like all the years that I've been in, recovery, like all the year, everything that I've done, I still have had some of this sort of repressed rage, that would come out, periodically, not to the extent, that it that it did with you. But enough where my wife would be like, you really need to figure out like why you're behaving this way or why this stuff kind of comes up and I'd sort of delayed it.
And I would rational I like well I'm doing all these other things. Like what else do I need to do? But there was this thing sitting there like just waiting, like a ticking time bomb that needed to be looked at and the fact that I, you know, took a week to, you know, just begin that process has been extraordinary. So I'm curious in your case. What did you discover in terms of that, that Rage, which I think probably a lot of people can relate to like, why do I get angry at this thing or that thing? Like how did that? How does that connect to your
Ask and how did you begin to, like make sense of that so that you could untangle it?
You know, I think as you obviously learned with Paul, I mean, I think there are lots of different types of traumas. There, a big treat Big T and Little T traumas right. There are sometimes it's easy to focus on the Big T ones and I've had a big T, trauma couple, I think. But what I think I learned that PCS was I probably been more undone by the little T, traumas, it's probably more some of the neglect.
and the sense of
I mean, truthfully, I think the single most important Insight is that I had never until I got there. And at this Murr, how they said, you know, you might be there for a week to three. I was there for three weeks. Like I was like one of the five percent of people that was there for 21 days. I didn't have my breakthrough there till the 19th day. I mean, two weeks and I thought I was better, I was ready to go home the next day and Paul called me and said, look,
We've all powwow and you know me Esther Terry, Katie, like the whole team has powered with their team and we think you were not quite there. There's one thing you're not willing to let go of
And I was like are you freaking kidding me? What? And they're like you heaven really accepted the fact that the child in you was really hurt by these things and these adaptations, they are not in the child's best interest anymore, like your response, these things that you did as a kid or not, normal childhood behaviors. If you saw your kid doing these things, you would be devastated by how sad it is. And by the loss of their
their innocence and by the loss of their childhood,
and,
For another words, sorry to interrupt. But in other words, the story that you'd been telling yourself was these things happened but ultimately they made me who I am and they gave me this engine and propelled me to do all of these other things and yeah, it wasn't great but like I've made peace with it. That's right. It was these things were really bad and I get it and I would never want my kids to endure these things. But you have to understand like they've been way more net positive than negative especially now that we figured out what these
- things aren't have coping skills for them and they were saying, no, no, no. You got to go back. Want perspective. Yeah, you gotta go back and realize, like this little boy, that never wanted to celebrate a birthday like that, this little boy, that wanted his daddy to be there and he wasn't there like those things aren't okay. And that, that kind of took me down into an emotional Free Fall. That was I think the final layer of excuses because I think you can probably
Late to this, but one of the ways I had rationalized my bad behavior for. So long was my kids aren't going to suffer what I suffered and I think that addicts can sometimes do that. They can sort of say like, you know, well, but you know, I'm making this up, this wasn't the case in my case, you know, my dad used to beat me with a belt every single day. And look, I'm not beating my kid with a belt every single day, so it's fine. Meanwhile, give me a medal. Yeah. And, and
I think that that that was also a very important part of my motivation was when I finally realized how much I was hurting my kids. It was they weren't actually experiencing the traumas I experienced.
But I was, they were experiencing a whole bunch of new ones and the kids have alcoholics don't always go on to become alcoholics, right? Yeah. But that doesn't mean that trauma isn't intergenerational. It really is, it weasels its way down and that that that realization coupled with being at Rock, Bottom was sort of like, you know what? I'm going to stop it. I don't want, I don't want this going to my kids. Yeah. There's a couple quotes from
um, the book that kind of, really hammer on that point, one of which, is this idea that children take on the shame of those around them, like, understanding that even if on paper, you feel like you're the dutiful dad and you're protecting them etcetera, that all of this emotional dis-ease, you know, percolates into their conscious awareness, and impacts them and their behavior later in life, and the other one being
You know, this idea of covert male depression and this this statistic that ninety percent of male rage is helplessness masquerading as frustration. Like that's a Zinger it speaks to me and you know look I did that was something Terry told me one day and in a therapy session and I was talking about it with Esther recently or not recently like recently after that or shortly after that. And she said, I want you to write that down on a Post-It and stick it on your monitor. I mean, it's
And it's so true. How often do I find myself even today? Getting angry about something? And if I just stop and think about it, I'm helpless, I feel helpless, I feel powerless. Yeah, and we're just, I mean again, I think for men in particular, it's very difficult to articulate that and accept that and it's so much easier to just channel that helplessness into some form of anger, mmm-hmm, or workaholism, or exercise addiction or any number of
Dalit. He's that, you know, basically Society isn't going to frown on too hard and you can get away with and and may very well even make you successful which makes it so pernicious? Yeah, that is. That is the, that's the irony, right? Is a lot of the people that I met in both the bridge and PCs had all of these, socially unacceptable, addictions. And I think by the end of it, I came to realize we're pretty much all the same. There's no difference between us do on that Journey from sitting there, just
All the differences while you're not like any of these people until finally you realize it's kind of all the same hotel to one of the thoughts I had when I left was, would we be better off? I wonder what you think about this bridge right now? When you look at sort of recovery programs, they're often organized around the end State. What's the addiction? So if your if your weakness is alcohol drugs, sex gambling, Etc workaholism Perfection, like we're going to organize those people together.
I almost wonder if we could organize it more by root cause like, if your shame is the result of this type of wound and that drives you to do this, this this, or this like, you should spend time with these people to. It's almost like a matrix approach where we think about what the, you know, end state is, but what the root causes were as well. Yeah. And there might be some benefit in both of that because that's what I found really.
I found really beautiful. Actually was getting to know so many other people through these experiences at both the bridge. And these are people I'm still in touch with like we still have a text thread. This is like five and a half years ago and
Everyone's story is different but boy it was the expression like history never repeats itself but it sure rhymes. Like there are some really common patterns here and I think everybody sort of feels alone sometimes I think that it really is you know, cheater to your question of, you know, root cause versus manifestation addiction, the addiction is the adaptation. That is the, you know, humans.
Tempt to try to cope with the root cause, and it works for a long period of time. Or you wouldn't do it and then it stops working, right? And then it creates chaos and havoc, and, and all the rest, but my, the kind of drum that I've been beating is, is really that it is all the same thing and you can quibble around, you know, differences in root causes this trauma that trauma. But you know, Paul or Gabor mate or
Stir would probably agree that so much of it is so deeply rooted in something that happened in your childhood, whether it's a big T or a series of little tease etcetera, but then you're correct. Like, is it alcoholism heroin addiction? Gambling, whatever, to me, it doesn't matter. Like it's all the same thing and addiction lives on this huge spectrum and I think almost anybody is going to be able to identify themselves if they're really being honest with themselves. If they do
Do you know rigorous inventory. They're going to see that that you know, there somewhere on that Spectrum. Maybe they just scroll a little bit too much on their phone or they keep getting in involved with the same kind of bad relationship or what-have-you. It shows up in, you know, innumerable ways. But ultimately it is the same sort of, you know, compulsive behavior that drives negative outcomes that you perpetuate and feel, you know, unable to control.
That ultimately escalates. Right. So whether it's a substance or behavior, what have you you know, our our outward manifestations are different. Although there's some overlap in the kind of workaholism in the perfectionist realm but it really is the same thing and and I think that we need to broaden the conversation around the nature of this condition and you know, create a bigger, welcome mat for people to engage with it because I think this sort
Art of traditional, sort of secrecy around or the shame that surrounds. It prevents healing for a broader population of people. Like I may have gone into 12-step earlier had I not a little bit more about it or hadn't been, you know, it was so mysterious that I had a whole set of ideas about what it was and what it wasn't that maybe kept me from getting sober sooner, I don't know. But that's a big reason why I feel so strongly about talking about this kind of stuff and why?
I wanted to, you know, make your experience, a larger focus of this conversation.
Yeah, it's a sort of interesting to think about tight just talking about this stuff in still publicly at least feels strange but I but I really I think it's really important. Have no regret that I said ever in that chair I think people are going to really respond to it Peter and I you know, I think it's a great service to, you know, let people know that that you know, this was your experience and you were able to get to the other side of it. It's empowering and I think cause I think you know, a lot of people the people look up to you, they respect you.
They Revere you, and for you to say, hey, I'm a human being, and I had this experience, and this is what happened as a cautionary tale. But also as an exercise in male vulnerability, to model that I think is, you know, is is courageous and important. And also, finally sorry to interrupt. But like you mentioned, you know, your kids and how important that was in in your realization and in your recovery program and this idea of how we pass our, you know, behaviors in our church.
I was down the line is so important because I think the addict sort of thinks, well, I'm doing this but I'm not hurting anyone or this is my problem or leave me alone. But the pathology is much broader than that and you know, Terry's quote in the book was the one that was of everything, like I think the most powerful. So I wrote it down. I'm going to, I'm going to recite it. He says to you, family pathology rolls from generation to generation like a fire in the woods, taking down everything in its path.
Path until one person in one generation has the courage to turn and face the Flames. That person brings peace to his ancestors and Spares the children that follow. And this idea that you wanted to be that guy. Like I want to be that guy to, you know, I think for as difficult as this journey has been, and it will be, by the way. This is the most difficult journey. I will face the rest of my life. I don't think, you know, for his
As small, a fraction of the book is this represents from an effort perspective? I probably put more effort into this than even my exercise. Hmm, But that's the motivation and even it's also a bit of, you know, just
I got a lot to make up for, you know, I think I'm really lucky that my wife is still with me. Frankly, I don't think any other woman would have put up with me and so I owe them the best version. Yeah.
Well, thank you for that. It feels weird to like kind of, you know, switch gears. Now this point but you know, having explored that with you and this being a chapter in your book
And the importance of this, in terms of not just how long we live, but how well we live, like you know, what are the medicine 3.0 changes that we should be thinking about and what can individuals who read your book or or who are listening or watching this? What can they start to do to, you know, 10 to this aspect is important aspect of our
well-being.
It's a great question. I think the first thing is just, you know, I talk about this briefly but it's pretty unusual for someone who's out of shape to not know they're out of shape. Right? You know if you if you're having a hard time walking up a hill. If you're having a hard time climbing stairs, if it if it hurts when you get out of bed in the morning, it's hard to not know that.
It's really easy to be emotionally broken and not fully appreciate it or more to the point to be like me and be in total denial. I think the single most important thing, a person has to do here is if for no other reason and to no one other than themselves, start asking questions. Like are you, are you living in a way where your relationships with other people are healthy?
What what, what was modeled to you? What, what did you see? And if you go back and reflect on that,
Do you think that that represents the best version of how, you know, people can interact? There are, lots of tests people can take. For example, you've probably familiar with the adverse childhood events. Core the a score. This is something that's readily available online. I do recommend people take it, right? If you're sort of sitting there thinking like I don't know what trauma is. Well, this is a check list of 10 things, some of which are really obvious like you're raped. That's trauma, but your parents going,
Divorce, when you're a kid, is trauma, right? So, you know, when you kind of go through an inventory like that it at least gives you some sense of vulnerability. I think that we talked about this a little bit that it's a little harder for men to do this but whether you're male or female, I think you've you've got to ask yourself the question. Do you have someone you can really confide in? You have a friend that you could tell anything to you know, or is it a test for it? They call it.
Do you have someone you could call in the middle of the night? If something was wrong, if you can answer. Yes to that question. I wonder why right? Is it? Because you don't feel comfortable that you can share that, or is it? Because you really don't have that person in your life. I think everybody benefits from Psychotherapy and I don't think it's very sexy. What's very sexy today? What's very in Vogue today, it's like psychedelics, right? Like, you know, all you need is a trip to Peru with a shaman and
Going to be fixed. And I talk very briefly about this in the book but I've had most of these experiences and some of them have actually been very positive but they aren't the healing process. They are just disruptive, right? They just disrupt your psyche enough that they make you open to the change, but the change has to come from finding a therapist in my view who you are comfortable enough to be able to speak with. And I think it's rather agnostic to the
To your discipline. I do the important thing is that you are engaging with some modality from a place of openness and honesty. Yeah. And it's just as we would say, look you got to go get a blood test, you got to go get this test done. You got to go do these certain things like you should know your VO2 max, you should know your, you know, your bone mineral density. Should have a dexa. Scan. I think we should take the same approach here, which is, you should be able to have someone that you emotionally check in with
And someone who can ask you questions and get you thinking and provoke you a little bit and figure out what your state of emotional health is this must really fuck with your engineer's mind though, right? Because it's not, it's not a math problem. It's so messy and nonlinear. Yeah. So in our practice Rich, we have this thing called the longevity risk assessment, the lra. It's how we anchor are thinking about every patient.
So we believe that there are discrete number of things that are a threat to your life span and health span. So, in no particular, order cardiovascular disease cancer neurodegenerative disease Falls later in life Automotive, deaf, Orthopedic injury and destruction, disruption of emotional health. Those are basically the big seven. So you can see that each of those can interfere with lifespan or health span.
And for each of those things we have inputs. So how do we make a diagnosis to establish risk? Because our first goal is to rank order. Those seven to understand how to prioritize effort. So 25 things that go into the model, right? So what's your family history? What are your Labs? What's your, VO2? Max like that? The as you can imagine the hardest thing to get inputs for. Is the emotional health piece?
When I and then there's outputs that come out of this. So, based on how you rank them, that determines what your behavioral changes are going to be when I do this exercise for myself.
What do you think is my rank order? Remember, my family history is Rife with cardiovascular disease. What do you think is number one for me? The greatest threat to my longevity, our family, our emotional health. Yeah. It's number one on my list. I think I have emotional health. Number one thing I have cancer. Number two, I think I have at this stage, probably Automotive death. And being number three, you know, and kind of, by the way, atherosclerosis is like number seven for me right now because even though my family history risk is so high, we've basically engineered
That problem almost to nothing and yet, you're right. Boy, do we struggle with coming up for the inputs? Because only if a patient is willing to be this vulnerable, can we truly understand right. What their sense of purpose is what their the state of their relationships are where they find, Joy, fulfillment, happiness, all these things. And I'll be honest with like half my patients, never want to talk about that stuff, it just maybe three-quarters of my patients have no desire to get into that. Mmm,
And that's okay, you know, maybe they will one day or maybe they do with somebody else.
It's got to be well, let me ask you this as a question is, do you find that that is more the case with your male patients? Then with your female patients,
I don't think I've 11i large enough sample size to answer that, but I will say this
It's true for both. I don't know, I'd have to really think about the proportionality of it, but there is an epidemic of misery. I mean that it is and lonely, you know, the the the loneliness statistics seem to be creeping out pretty rapidly and, you know, the long-term implications of that and, you know, coming out of covid and how that fractured a lot of relationships or just sort of made us more
System to being cloistered in our homes and not with people. Like what does that look like? Played out over a number of years? I'm amazed it
Because I see it in myself so maybe I'm more attuned to see it in others. But the number of people who are so willing to work so hard,
At the expense of personal relationships. And again, I say that not in an accusatory tone, like, I say it is someone who does it. And I always worry, like, I just have to remind myself that, you know, one day this none of this stuff is going to matter. You know, I talked a little bit about a book that David Brooks wrote called the road to character. Was a very important book for me to read during this journey. I read it really when I was in the middle of hell and you know, it was one of those things. Like, there's no one thing that changed for me, right? It was an accumulation of things.
But
his framing of thinking, of your life via its resume virtues versus your eulogy. Virtues is something I still remind myself of every single day. Yeah. And and related to that is our guy Arthur Brooks. Yes. Of course, he talks about real friends and deal, friends, right? And, you know, the crisis that's visited upon many a successful person. When they realize all of that.
Success and the drive that led to that has perhaps created more damage than value and trying to put the pieces together and find a sense of wholeness with oneself and one's relationships, untethered to external validation or everything that went into, you know, accomplishing all of these things that you know, we delude ourselves into thinking, we're going to make us happy. Yeah, it's a tough. I have a real soft spot.
My heart for people who have achieved superstardom and I've been privileged enough as as you have to meet a number of these folks. And I think it's hard then again and I'm sure nobody sitting here, feeling, sorry for someone who's, you know, famous and Rich. But with it, comes a real sense of isolation and who's real and who really cares about me and who doesn't, and who's using me, and who has another agenda, and I think one needs to be thoughtful before they decide, they want to be a public.
Black figure. Yeah, I think that that's probably very true, right on the, on the subject of you mentioned hallucinogens. There was another quote in the book that I wrote down, where you say too often. I see people tethering their hopes of transformation solely to a ketamine trip, or a journey to the jungles of Peru with a shaman to guide them through the mind-blowing experience of an Ayahuasca Journey or some other singular experience.
Or even as in my case thinking, that two weeks in a facility such as the bridge is enough after which we can continue. As though, nothing fundamental has changed. And I think that that this goes to, it's not unrelated to the narrative around healthspan extension. It's this, it's this Allure of the quick fix or if I just do this, one thing all will be well and I can maintain my operating system. Yeah. It's sort of like imagine you've never exercised in
Your life, okay. So you're you're 50 year old, who's never exercised, by the way, a lot of people like you, right?
The trip to the bridge where the Ayahuasca Journey, might be the thing you need to realize, holy shit, you need to exercise, but guess what? Now you have to exercise, right? So I don't want to say like these things are good or these things are bad. But my point is in my experience, this emotional health thing is a journey that is rooted in Daily practice.
And some days are good and some days. Suck, meaning some days. I fail so badly and I feel so ashamed and I feel horrible that I was a dick to my assistant.
But one thing I learned that so important is that I can't remember. If it was, I think it was Esther. Who told me this and she, of course, she's so eloquent. She said it's so much better than this. She said, Peter, it's not about how many times you screw up at this point. It's making sure you make it right.
You know, and she was talking about through the lens of my kids. Like if you you're going to get mad one day and you're going to yell at your kids again, and it might, it might think it's Daddy of old, right? But it's like no, no. The difference is you make it right, right away. It's the, it's the healing that fixes it. And and then I'll give you a really silly example like on the weekend. My boys were running around playing around and our youngest is, you know, he's kind of going through that phase he's five and he's, he's just not listening to anything. Right? So and one of the things he keeps doing is he keeps running around smacking everybody in the but like
This is his favorite thing to do is, he'll walk up and smack in the, but as hard as he can 100 times, and you're like a hairy enough, enough enough enough enough, and finally have like the tenth time out. I just screamed in my area, get in your room.
And he just like, you know, ran into his room and I was immediately. I felt full of Shame. Like, you just scared this kid, you like, and I went into my office and started to work.
And then I was like, I have to go and fix this right now. I have to let him know that I'm angry at you because that's not what you're supposed to do. But I shouldn't have yelled at you that much and I go in his room and it was just such a sad awful reminder of what a childhood feel when a child feels like in shame. He wouldn't look at me. He was on his bed head down and I kept saying Airy listen I want to talk with you buddy or talk with you about what just happened. There's like, 10 minutes later.
He wouldn't look at me and I said Harry, listen, Daddy's really upset that you're walking around smacking everybody in the butt but I shouldn't have yelled at you like that. I'm really sorry. Can I can we hug? And he wouldn't, you know, it was like an hour. He was really, he wouldn't come out of his room for an hour.
So I think in the olden days I would have just beat myself up over that for so long. And I would have continued, I would have actually taken it out on him more paradoxically, but instead within an hour, everything was fine. And we kept talking about it and I was like, look, Harry, you know, why? We don't want you doing this, you can't do it at school. You can't like, you know, it's not like we're not going to discipline you, but I'm going to make sure that I'm not blowing up at you because I'm frustrated. That's a silly little example, but it it's the that's the interstitial fluid of
What this stuff is about, it's making mistakes fixing mistakes, as opposed to beating yourself up and making bigger mistakes. Yeah, couple insights on that. I mean, that it's about the half-life, right? So, the, the period in between the negative action and the immense or or you know, kind of reaching returning to some level of equilibrium shrinks just like in meditation, you get that little extra gap of time to choose how to respond rather than to just impulsively.
We react super important and the more you practice that you get better at it early in recovery a guy that I know. Shout out to my boy, Scotty said if you're going to eat crow, eat it hot, right? So it's like, you're going to fuck up like, just just deal with it right away. The faster you deal with it. My instinct is to like pretend it never happened and deny it and of course it just metastasizes and gets worse and worse and worse. I think with kids the other layer to that.
It is making sure that you're not projecting your bullshit on to them. Like, you think like I'm I need to make this, right? I'm going to go to my kid and I'm going to make the amends and apologize, but your kind of vomiting your own bullshit on to them and it's not for them to take on your dysfunction like oh I'm so sorry. And this is my thing about it's like that's just actually making it worse and so for me a lot of a lot of the, you know, the the
Work is around, like, maintaining my container. So I'm not, you know, pouring out all of all of that kind of nonsense and putting it on the kid and I'll do it without even being aware that I'm doing it. But give me an example.
I think that we often try to parent in opposition to the dysfunction of our own parents, right? So I grew up in a household in which my mother was very afraid of everything like extremely fearful and worrisome and would kind of vomit that on to me, which then made me a very risk-averse person or thinking the world is threatening and dangerous. Of course, I don't want to do that to my child but then I'll catch myself like well we're just
Worried about you or like I just, you know, I care so much about you and I don't want you this and it's like I'm doing it. I'm perpetuating this pattern. I'm doing the very thing that I promised I would never do and I've convinced myself that I'm doing it out of concern, for this person but that's not really what it is. It's some kind of weird programming, interesting that's built in that, that I'm that I'm, you know, unless I'm mindful I will just default to
I mean, it speaks to this point in his life long journey. Yeah, and I wish that it were easier, right? Like, I wish that there were biomarkers that I could follow for this the way I can followed by our March. Right? You crazy. Well, I mean you can't get in a simulator. Yeah. So the simulator is life. Yeah, we're in the simulator. All right, we've got almost two hours. We haven't said anything about exercise or nutrition. I'm sitting here in the back of my mind as I'm listening to you talk like debating like
Do we even do that now? Like I think people will kill me if we don't spend at least a couple minutes. We talked a lot about then we talk about exercise a lot in the first podcast. Yeah, we talked about we did a lot on Zone 2 and on on vo2max the importance of, you have a whole chapter in here on the various modalities of exercise. We're told to exercise, but what does that actually mean? Here are the pillars that you need to be building in parallel strength, endurance, of course. And you explain all.
All these things stability exercise is probably the biggest section of the book, it's three chapters. So there's more, there's more, you know, more more air time is devoted to exercise than anything else in this book. What's interesting about that and like, yes, I don't want to, I don't want to like, go over stuff. We've already gone over, but there's two things that I'm curious about the first, is, there is this adage that you can't exercise your way out of a bad diet. So that leads me to believe that actually nutrition is more important than exercise. Your thesis is that
Exercise is by far the most important. I think that added stems from the if you're purely thinking about it from a weight perspective, right? So if you're, if you're thinking about it, as X is exercise, the best tool we have for weight management. The answer is no nutrition. Is the inputs matter more than the outputs on weight management due to the adaptations that come from energy expenditure. In other words, if you take a person who's, you know, going to ramp up their energy expenditure by 1000,
Calories a day, they're going to accommodate by eating more as well. So if it's a weight management problem. Yeah, you can't really exercise your way out of it, but I would say sorry, I know you're in the middle sharing an additional thought but just to interject your quickly what comes up for me, in thinking about heart disease and neurodegenerative disease, both both of which are diseases of the circulatory system and and me having this in my lineage that means
That I need to be more careful about what I'm eating and yet despite that adage when I'm training a whole lot. It's like yeah. But I'm like burning so many cases like I can like this is not going to be that big of a deal to now thinking like actually this is like I do need to be really careful about this kind of stuff. You know. You alluded to this just briefly a while ago which was the science around nutrition is like the murkiest of all the signs. If I
Think about okay. We just talked about how squishy emotional health is so let's put that aside for a moment but if you want to talk about pharmacology, sleep exercise. Nothing is more murky than nutrition. I don't need to explain why I write about it at length so let's just pause it that that's a correct statement. Yes, it's that there is no field of human health for which the data are more ambiguous.
I was half tempted, the editor would not, let me do this, I was have tempted to make the Nutrition chapter, instead of being two chapters that probably total 80 pages to make it one page, which is this is all we know about nutrition.
If you want to be black and white, this is all we know which is, don't eat too much. Don't eat too. Little there are certain micronutrients, you need to have avoid things like e-coli. Like it's there's like ten things that I can tell you with absolute certainty and obviously, nobody would care to read that. Of course, I expand it on all of
that.
As it comes as it pertains to nutrition. I've I've really changed my tune over the last 12 to 14 years and where I stand. Today is not where I stood, you know, a decade ago not at all today. I believe that energy balance is the single most important driver of ill health as it pertains to nutrition.
I think that there are lots of different ways to regulate energy balance, and there are lots of third, and fourth, and fifth order terms, and I write about those in detail.
What types of fats are more healthy? How much protein animal versus plant protein all of those things?
But at the end of the day, it's really my conviction. And I, you know, this, if there's one chapter that I shared with more people as experts to get input before I finished putting pen to paper, it was this chapter because I wanted people who kind of had different points of view for me. And what do you think about this? What you think about that? And what I've distilled down is energy, balance, matters and matters the most. So that's an input equation. Not an output equation. So we exercise not to burn calories.
We input we exercise for this structural and metabolic benefits but not the energy. Expenditure benefits per se on the input side to to regulate input. You basically have three levers that you pull you can either. And again this is not something, our ancestors had to think of because food was relatively sparse, but in our environment today, most of us need to think about regulating
I'm in the certainly I do, there's no chance I can walk around eating as much as I want whenever I want and whatever quantity. Right undernourishment is a is not the, the low-hanging fruit problem. That's right. I do have some undernourished patients, but eighty to ninety percent of people are dealing with, you know, being a little bit over nourished. So our strategies are can calorie restrict. We so we can literally just say independent of when I eat or what I eat.
I will eat less.
We can do dietary restriction, which means I will restrict elements within the diet or we can time restrict. I will restrict when I eat each of those has its pros and cons
But ultimately, they're in service of the same thing which is consuming less
Now, once you make the decision of which of those pads, you go down and they can be mixed and matched, right? Like you can say, well, I'm going to be on a plant plant based diet or keto diet. And I'm also going to only eat between 8 a.m. and 2 p.m. like there. Again, these things are totally mixable. Then the question becomes, okay. There's four macronutrients carbohydrates fats, proteins and alcohol. How much do you emphasize each one?
Start with alcohol because it's the easiest it technically serves no purpose in our diet. So it's a, it's an isotonic pleasure. But I deconstruct the data and make the case that there is no dose at which it is healthy. Despite what some of the really bad epidemiology tells you which is that there's a reverse J curve and technically like one to two drinks, a day is really healthy and abstainers have the, you know, have a slightly higher risk of mortality, that's not true at all. So zero alcohol is the best probably up to
One drink a day has minimal effect, but after that it starts to actually climb up. There's lots of other reasons to avoid alcohol, by the way, especially if you're in the business of trying to lose weight because alcohol is itself a very oxidizable fuel. So it's the body's going to preferentially oxidized ethanol before it oxidizes, everything else. So you don't really want to turn off fat oxidation. If you're trying to lose weight or postpone it or delay it, or move it down the Q, you want to keep it front and center so it's just an unnecessary calories.
It was and sleep just regular absolutely decoration. Also, if you're anything like me any time, I drink, I want to eat more so it's it becomes this counterproductive thing. So it just look. I'm not going to sit here and say don't drink. I do. But understand again it comes down to risk. Understand the risk? Is it worth it? You know, I refuse to drink anything that isn't exceptional. So if someone serves me a glass of wine and it doesn't taste amazing. I'm not going to drink it. I'm a snob in that regard. It has to be good if I'm going to take the risk.
When it comes to the next three. Macronutrients, protein is where I place, most of my emphasis, this is the one where I really want to make sure my patients are getting one gram per pound of body weight. And the reason for that is that the maintenance and preservation of lean muscle, mass is such an important part of living, long, and Living. Well, sarcopenia is such an underappreciated, cause of quality of life reduction sarcopenia, meaning loss of lean mass.
Strength. But how much of that is the result of lack of proper exercise versus protein intake? Like, both I know you, you know, you you have this perspective on protein but are people walking around not eating enough protein, like it's hard for me to imagine that, that's truly the case. And I understand, especially, as you age in these later decades, that it's important to make sure that you're getting enough protein, and you're doing the kind of exercise, you need to maintain and build.
Build lean, you know, muscle mass, it's very hard to maintain lean muscle mass. Once you're our age, we become anabolic Lee resistant as we get older. So what a 20 year old can get away with paradoxically is less than I can, and that's going to be less than what I can get away with when I'm, you know, 70 and 80 years old. And that's really the game. I'm playing. I'm playing a long game, so I'll give you an example. If you look at some of the epidemiology, which we can discount,
Count pretty quickly. But even if you just take the epidemiology on face value, it would suggest that for people under 50, eating less protein is associated with lower mortality. And for people over 50, eating more protein is associated with lower mortality. And on the surface, you sort of think, well, I can see why. When you're older, you might need more protein because of the antibiotic resistance and all these things.
Even if the difference in those mortalities was identical in relative rates, you would still favor a high-protein strategy because of the absolute difference in mortality. In other words, your mortality is much higher when you get older. So even an equivalent relative reduction in that risk, would be a far greater impact on actual mortality. But an added complexity to all of this is, is what that
Protein is packaged with right protein, you're not in taking protein in isolation, unless you're just doing protein powders, right? So, is that protein coming in the form? In something? That also has a lot of saturated, fat, Etc. What are the considerations that come into play with that versus plant-based proteins, absorption issues, ETC. Like it starts to, you know, the, the, you know, it starts to the complexity of it. Yeah, and pretty quickly. So those are
Different things. Which was you talk about? So, we'll start with the bioavailability. So, animal protein is simply more bioavailable than plant protein that generally has to do with the fiber that's associated. With plant protein, that's an easy problem to overcome. There's two ways to overcome it. The first is you cook the plant, right? So when you, when you liberate that fiber, you make the plant protein, you make the plant protein more bioavailable. You can also just consume more of it. So you can do this in a really technical way using, you know, diecast scores and things like that. Which I
Don't recommend for my patients. Who are plant-based. We typically tell them how many grams of the most important amino acids. They need to eat in a day. So we're basically saying you need this much, leucine, you need this much lysine, and you need this much methionine. You're going to have to eat more protein to get them because you don't get, you know, if you're not eating an egg, it's going to be harder to get like you can get a gram Athenian in the single egg, but if you're not eating an egg, you're going to have to go around the block to get it.
So instead of saying, look just fixate on a total amount of protein, that seems a bit abstract. It's getting them to understand how this food has this much leucine lysine and methionine, and focusing on that. And again. So now you're focusing on the important, you know, acids, as far as the fats that they're packaged with, I think of everything I write about in this book, there is no area in where I was more frustrated to not have a more definitive point of view. Then on the relationship.
Between saturated fat, monounsaturated fat and polyunsaturated fat. When it comes to human health, virtually, all of the data on this subject matter, pertains the cardiovascular disease, and I spared no expense at turning over every stone in looking at this and it became literally one of the most unsatisfactory things I've ever done in my life. In terms of how uninteresting the results were basically the summary is this and this is where I kind of end out myself is
the safest thing appears to be monounsaturated fats, right? So if you're going to do it on the basis of the Lyon heart study and the predamond study which are really the two best studies, we have them in the predamond. Study is hands down the best nutrition study we have in the history of our species. It makes a pretty compelling case that a diet high in monounsaturated fat is at least superior to the other diets that were tested.
The epidemiology seems to validate that, the next question then becomes, and I would have assumed the data would have been very strong in favor of polyunsaturated, fat, ahead of saturated fat. But as you know, you have all these different camps and tribes. You have this one group of people who say polyunsaturated fats are horrible, because seed oils are the devil and the real live, is it really hard to find compelling data to make that case? If you look at the most relevant, most extensive Cochrane collaboration
ones, which are these are meta-analyses that are hundreds of pages long and I've gone through these
You could argue that there is a slight benefit to displacement of saturated fat with polyunsaturated fat when it comes to reducing the risk of heart disease. But my view on this problem is it's a bit of a major in the minor in minor in the major because most of that downside of saturated, fat seems to be transmitted through its effect on lipids. So there's no denying that a diet high in saturated fat for many people will raise atherogenic lipids.
I have stopped trying to fight this problem because for most people we can control it so easy with pharmacology. That what I say is I want you to come up with the diet that is going to be the best for your other things. That I have a much harder time, controlling pharmacologically your energy, balance your, in your, insulin, sensitivity, and your inflammation. I can measure all of those things. By the way, they're just very hard to control with a drug, so I want to control those with your nutrition.
And if that means, you can only fix that with a diet that has a little too much saturated fat in it. And it's driving up here a poby that's okay because that's the one thing I actually can control really well. Mmm. And for other patients, that's a diet that's really low in fat or that's a diet that has very little saturated fat for the past, six months, for the first time in my life. Actually, I've never done this before. I've been tracking everything I eat just out of curiosity, just to see like, because I'm not really trying to restrict anything. So the only effort I'm making is getting my 180 grams of
In a day, everything else is just, I'm like, kind of curious like, how much fat am I eating? How much carbs am I eating? I have a weird diet, like, I'm equal, fat and carb and high protein. So, I think I'm working out to be about I'm like, probably 35 percent carb, 35, percent protein, 3335 carb, 35 fat, 30 protein, totally weird. Yeah, that is, we're totally weird. I think you say in the book, that for whatever reason you seem to have a high tolerance in Europe,
Bility to eat saturated fat without any kind of Downstream. Yeah. When I was on a ketogenic diet, right was for three years. I was an acute Panic died from 2011 to 2014. There are a couple of, you know, confounding factors. I was also training like crazy. I mean, this was sort of peak adult training performance for me, I was averaging at least three hours a day of really serious training.
But I mean, I was getting 80, 80 to 85 percent of my calories from fat and probably half of that was saturated. And my lipids were not out of whack at all. I mean, I was, I mean, you look at any biomarker of me in that era. I mean, my triglycerides were in the 30s. My HDL cholesterol was high. LDL cholesterol was modest if it was below. The 20th, percentile has to be unusual, though. Like it is, I could not do that. No, I didn't come anywhere near that. Oh, and I'm healthy. Yeah, I don't, I don't, I don't know why it
happened in me. I've seen a few other people for whom it works as well, but I think it's the exception and not the rule, and I've also had some patients who they've gone on ketogenic diets, everything has gone. Well, except there a pub, their cholesterol goes through the roof. They look like, they have familial hypercholesterolemia and I say, well, we got two choices, because I don't like this.
Either we drugged it, or we try and experiment which is if you really feel hell-bent on being, in this ketogenic diet, would you be willing to totally change your fat composition?
And in the cases where patients have said I really want to stay on the diet and I don't want to be on a drug yet. Let's go all monounsaturated and higher polyunsaturated and really cut down the saturated to like 25 grams a day. And in some cases, not all cases, in some cases about half the time it fixes it. So saturated fat, I think drives atherogenic particles by driving up the synthesis of cholesterol itself but also by impairing
the liver and more importantly I think by impairing the livers clearance of cholesterol. So it's a tricky molecule, it gets complicated. My brain wants to make it simple ldl-c. Hi no good apob, you know, you're not in range bad, you know, like these are things that, you know, need to be addressed immediately. Then I'm on my phone and I'm scrolling through Instagram and people are, you know, literally, you know, peeling, a stick of butter, and taking a
Right out of it. And then, you know, and then eating their steak for breakfast and talking about how everything you've been taught about LDL dietary cholesterol. All of that is nonsense. This is, you know, the way that we should be eating. And and there's a lot of people who are very influenced by a number of people who are who are advocating for this way of eating. So you know, care to comment. Yeah. It's
Very disappointing for me to see that kind of stuff. I try to stay as far away from the diet Wars as possible. Yeah. And this, this book is the furthest thing from anything tribal like it. You know, you really have in a culture in which there's a sense that if you, if you want to make an impact, you have to, you have to be, you know, somewhat extreme or have some kind of contrarian perspective, everything that you do is lives outside of that, you know, it's all very grounded, but sorry, I interrupted you again.
Just look up seen. I've had patients show up to my practice throughout that are on, you know, incredibly extreme diets. And I just, you know, I take it as my, you know, first of all, I feel like I've got the time to work with somebody so I don't have to solve this problem on day one. All right, so if somebody shows up in their own like the carnivore diet and the reading steak three meals a day and putting butter in their coffee or whatever, I don't know if that would be a carnivore die. But whatever and their Labs look horrible. I say, well,
Let's talk about this diet like what suit? What is it doing well for you? Why do you like it? Oh well, I feel great. I've lost all this weight but it I said, great. Okay, let's talk about why those things might be happening, and what do you not getting from this diet? So they'll say, well, you know, plants are toxic, and I say, okay, let's, let's think about that for a minute, right? Let's go down the like, is there any data to support that, right? And look, if you get somebody who is intellectually honest, you might say. Well,
Don't dispute that you might feel better having gone from eating a standard American diet, kind of a lot of stuff in it to being on this highly restrictive diet. The question is, you took 57 things out of your diet and you feel better? How do you know which of the 57 things? It was, don't you think we ought to go back and try to do this in a slightly more thoughtful way because I would say we don't really have any evidence that the diet you're on. Now is sustainable
It might be again, this gets too kind of risk and uncertainty like it's possible that humans can live on that diet and be perfectly healthy. It's just improbable and when people have their blood worked on and they see these elevated markers and are told not to be concerned about that, that feels I probably devote more airtime to trying to dispel those myths and actually did a recent AMA. Just on that topic, which was on, again, the causality
Ality of apob. This is such an important concept. I mean it's come up now. Three times because it matters. If something is causal
Then anything that increases. It has to be viewed as problematic. Here's what's not causal HDL. Cholesterol is not causal.
A lot of people justify their elevated LDL cholesterol or apob by the fact that their HDL cholesterol also goes up and their triglycerides. Go down. And so they say, well, look, we know that high HDL cholesterol and low triglycerides, are associated with lower risk of heart disease. So, who cares if my LDL cholesterol is high? Well, here's the problem. When you look at both the clinical trial data and
The mendelian randomization data, they're all in the same direction, the mendelian randomization data explain in a moment. What that means if people want to understand make it abundantly clear that high HDL cholesterol is not causally associated with a lower risk of heart disease and low HDL. Cholesterol is not causally related to a higher risk of cardiovascular disease. Therefore
it doesn't matter if they're higher or lower, they're not causal conversely, when you look at LDL cholesterol and you look at all of the mendelian randomization 's and all of the clinical trial data,
It all moves in the same direction. Higher LDL cholesterol is causally related to more a scpd. So when someone says to me, these two biomarkers got better. And this one got worse, I'm going to ignore this one and pay attention to these two. I say you're ignoring the causal one in favor of the to non-causal ones, that's a bad strategy. And and explain the difference between ldl-c and apob in terms of, you know, a blood marker
That one should be paying attention to, but I'll give a real gorilla primer on cholesterol because I think it's important as in, right? So our body, every cell in our body makes cholesterol. It's an essential molecule for life. So despite the fact that it's sort of been demonized. If you couldn't make cholesterol in every cell in your body, you wouldn't have been born. That's how you would have been lethal in utero.
So, our body has to kind of solve a problem, which is it needs to move cholesterol around the body, but cholesterols fat and we can't move fats around in water and we use our circulatory system which is water to move fat around. So we have to come up with a way to package them in water soluble things, these things are called lipoproteins, some of them have high density, some of them are low density. Some of them are intermediate or very low density, so the low density lipoprotein.
Called LDL happens to contain a lot of cholesterol, audits cholesterol and triglyceride. The ldls are wrapped with a protein, called a pole. I protein B. There's one and only one able lipoprotein be on every LDL. And there's also one on every other atherogenic particle in its lineage, which is the ideal to vldl and the lp little a
In this sense, a poby is the most important biomarker we have with respect to lipid burden because by knowing the concentration of a poby, you know, the exact concentration of the total number of atherogenic particles. So it is a better predictor of cardiovascular risk than LDL cholesterol, which is the more common test that is developed, which just looks at the amount of cholesterol within the ldls. So one is saying how much cholesterol cargo
you have in the LDL particle. The other one is saying, how many total particles do you have of not just LDL, but the other Bad actors I got you. And, and apob is, it's relatively. It's only relatively recently that it's kind of come on the scene as the thing that people should be looking at, right? Like this is finally I do for you. Yeah exactly. Like sweet women 2.0. Sure sure. I mean Alan snyderman has been you know screaming about this for three decades.
Believe it or not, the US has the last country to come around on this. It's been largely entrenched in the ldl-c Dogma, but you're right now. It's becoming more mainstream and we encourage anybody to go out and say to your doctor. Not only do I want my lipid panel. I want to see my LP little a hey, I want to see my a Toby. What are some of the other tests that should be requested in terms of scans? And we can start with with heart health, the calcium scam, but there's
There's like soft black scans now and think other time. Yeah, we're I prefer CT angiograms over calcium scan. So calcium, scan is just a quick CT scan of the heart with no contrast and it will only show calcium but fifteen percent of the time it'll miss it, it'll either Miss calcium or Miss soft black. So it's a CT angiogram which is more expensive and has more radiation, but if Done Right, still has, you know, less than 45 percent of your total annual allotment. Irradiation is a much better test.
And I think these serve a purpose but they don't have to be done on everybody, right? So they're, they're helpful for people who are on the fence about treatment depending on their age. So if you have a young person who maybe has a higher family history risk but they're kind of ambivalent about being treated maybe seeing that they already have a finding on their CTA is the thing that they need to move ahead. Conversely, if you have a person who's really old
And their numbers look really horrible, but they also don't want to be treated seeing a completely normal. Scan at a really Advanced age. Could also maybe steer you off treating, right? If they're resistant and and how it would seem to me that these tests for heart health would not be unrelated to to understanding risk for neurodegenerative disease as well, right? Given that they are diseases of the circulatory system but otherwise testing
a other than genetic testing. There doesn't seem to be a lot that you can do to predict these or to see where you're at, in terms of the development of those diseases. Well, when it comes to Parkinson's disease and Lewy Body dementia,
It's a little harder than with Alzheimer's disease, I think with Alzheimer's disease, the apoe genotype is the dominant gene not the only one. There's at least 20 genes that are playing a role in those diseases in in ad specifically but apoe is the dominant one and that's an easy test to get but it is important that people understand what it says and what it does it says right here and what doesn't say so apoe is not a causative Gene. It's not a deterministic gene. It's a risk Gene.
Mmm. So fortunately only about one percent of people who develop Alzheimer's disease do throw do so through a causative pathway where there's a deterministic gene that guarantees, they're going to get the disease, there's three genes. I won't bother naming that account for 1% of Alzheimer's disease and if you have one of those three genes, unfortunately you will get Alzheimer's disease. This is an awful set of genes and they typically afflict people very early in life. So when you hear about,
Someone who got Alzheimer's disease in their 40s or 50s. It's almost assuredly. The case, I write about this in some length in the morning. I write about it, not so much because it's such a big problem, but because it's where the diagnosis and nomenclature around Alzheimer's disease, came from and I believe it's part of the root cause of why we have such a hard time understanding the disease today with with Chris Hemsworth in Limitless. There's that, you know, amazing sequence where you have to tell him that he has this.
Double marker, which creates this enhanced risk for Alzheimer's. But that's I mean, what percentage of people have that two percent of peace that one to two percent of people, it's very rare and it was, you know, pretty shocking. When we got his blood test back and I certainly wasn't expecting that. Yeah, I mean, how did how did that go and like how has he changed some of his lifestyle habits? As a result of that news?
Well, when I said that the whole plan for that was we did a blood test when Chris was in LA it was like the end of 2019 and we were going to start shooting in January 2020 in Australia and the plan was I get the results back but I would never talk about it with him until we were on camera and I would that's fine. I get it but then I got the results back and I saw that he had the e4e for combo and I sort of thought about it for a day and I was like, yeah there's just no way.
Like it. This is a hard discussion to have with a person under any circumstance because the moment you start talking, they're only picking up a fraction of what you're saying, once they hear Alzheimer's disease risk, higher.
Do you really think that they're going to pick up on the nuances of it's not deterministic and we have things that we can do to mitigate risk and there's other genes that can offset this like no chant and I know this from experience, I've had this discussion so many times it never, it's like that seat in that scene in the movie. Contagion where Matt Damon's being told that his wife is a needed heat. Doesn't hear any of ya. So I called Darren Aronofsky. Who's the director? And I said, hey I know that you guys wanted to do it a certain way, but I got to talk to Chris about something and I can't tell you
What it is because it's not your, you know, this is his between him and I. So you got to take a leap of faith on this and decide that it's okay for me to kind of break this one part of the filming and do it. So. So Darren just had Chris call me directly. And then we sort of face time he was sitting there in Australia with his wife, you know, hanging out and just had that discussion with him and I think he was kind of like
Okay. So what does this mean? Explain it? Okay? Okay, all right, so what does it mean? And which is again, the totally normal response and then we didn't talk it about. We didn't talk about it again until filming, which was probably like three weeks later. And then, of course, after that we got and I don't remember what that's like, but I haven't even seen that episode. So I don't remember anything of how it happened. That's been over three years but then since that time it's become, you know, a much bigger, you know, he now he really understands
It's it right? Like now he's he's dug in deep and he understands. Okay.
My risk is going up this amount. You know, we've done a bunch of other things to look and, you know, done some scans and made sure that. Yeah, everything looks perfect right now. But now, you know, your highest priority from the standpoint of your longevity is probably going to be taking a bunch of steps to delay this thing as long as possible or frankly eliminate it. And by the way, there are lots of people with apoe4 genes who do not get Alzheimer's disease.
Yeah, it's heavy. You talk in the book about another, you're one of your patients a woman who in the similar situation, you know is on the receiving end of that news but you know having 25 years to work on this you know in advance of perhaps any symptoms showing up whatsoever and that's really the Crux of where your, you know, your focus as a practitioner is like how do we use these intervening years with this understanding, or this indicia that something might be happening.
Going to divert it delay. A think that's where there's a really big divide also between medicine 2.0 and Medicine 3.0 and there's probably no greater example of that than Alzheimer's disease. I think it's very difficult for medicine 2.0 to acknowledge that this is a disease for which prevention is an option and there was a lot of you know Darren Aronofsky after Limitless came out. Forwarded me a some text that he got from some angry people.
Mmm, like how irresponsible of you to do this. How dare you, like tell, you know, have Chris find out that he has this Gene? Like, your people were really pissed off, not all of them, of course, but some of them and I, you know, Darren said, what do you think about this? And I said, look, I'll tell you what. I think about it. I said I think that just demonstrates a person's bias. This is a person who obviously, you know, believes that the best thing, you know. They're let's just assume that this is a good person. First of all, this is a person who is in their best interest and they're in
Our best judgment believes that. Nothing good comes of telling Chris that news. Well, let's dig into that assumption. If nothing good comes from telling somebody that news by definition, you believe, you can't do anything about it by definition. You believe, this is a fait accompli. And I just said, look, I'll show you tons of data that say that that's not the case. I'll show you tons of data. Let's say how you eat, how you exercise, how you sleep, how you manage hearing loss, how you manage?
Depression. Those things are very related to the development of dementia.
So we says, empowering it because it gives PL agency and to do these things irrespective of, whether that person ends up with Alzheimer's, or not, or any number of other chronic ailments is in your best interest to do anyway, right? Like, all of these things are going to make you healthier and happier, you know, delay, these chronic illnesses, but even in the event that you ultimately succumb, or whatever you're doing, what's right for yourself and your long-term Health. Well,
Just as, in the exercise sections of the book. I talk about, you know, Reserve right? You want the highest vo2max possible, so that you are starting at the highest place. When that decline kicks in, right? You want the most muscle mass, you want the strongest body possible? Because there's nobody that, if anybody's coming here to tell you, you're not going to decline like they're crazy like, we're all declining.
So the goal is maximize your reserve half as much water behind the dam as possible, so that when the drought comes, you can survive longer. Well, this applies to cognition as well.
And that's why I pretty much am doing every single thing in the e4e for Playbook myself.
And I would encourage everybody to be doing that. In other words, we should all act like we're Chris.
Because whether you're e 3 e 2 or E for you're not immune to this disease and even if you don't get the disease or even if you looked in the future and you had a crystal ball and it says okay you will not get Alzheimer's disease. It doesn't mean you won't cognitively look line. We're all going to cognitively the crying. So what you know, why does sleep matter? Why does exercise matter, why does insulin sensitivity matter all of these things matter because they're going to continue to preserve as much cognitive horsepower as possible, for as long as,
Possible independent of a disease State. Hmm we talked a lot last time about the centenarian decathlon so I don't want to repeat that but I did want to drill down on one thing which which seems to be like this. This thing that you're you've been hammering a lot on social media which is grip strength. Like this is your this is your jam right? Let's talk about everything straight dollar. What the fuck is up with grip strength? You know, hanging from a bar being able to open a jar and all why is that a problem?
see, for the kind of strength that's important to be working on and thinking about as we age,
So we really only have two ways that we interact with the outside world, right? Most of us are not walking around head-butting things these guys and our feet. So anything about those things that are not working perfectly leads to big problems, will save feet for another day because that's a whole enormous problem. That works. Its way from feet to ankles, knees hips, and back in the rest of it, when your grip strength, suffers it limits your ability to do pretty much anything with your hands from opening.
A door opening, a jar, pulling something all of those things. So I mean, just start with the data, right? So if you look at the data and I include a figure in the book about this, right? If you look at the assess, the strength of the association between grip strength, and any disease, all-cause mortality. I include onset of dementia death from dementia, doesn't matter, the stronger, you grip the longer you live and we can never do an experiment to see and prove that that is causal.
We can do is we can look through the Austin Bradford Hill criteria of epidemiology and check off all the boxes that say boy. Most of those things suggest that this Association has causality built into it. Is it the grip strength itself or is it the fact that somebody with good grip strength? Is probably doing lots of things for their overall strength and well-being. Think it's more the latter than the former I think grip strength. Just happens to become a very good proxy.
For because if you have a strong grip by definition, you're strong here, here you probably have some, you know, you probably have stable scapula, things like that. It's also an easier thing to measure. You know, it's we like that's why VO2. Max is such a strong association with lifespan. It's not that it's the strongest thing. Like that might be something out there that stronger that we haven't measured. Maybe if we took the time to measure, lactate threshold, we'd see that. It's even slightly better. It's just that it's very reproducible. It can be done across any lab, any study.
And it's been studied in millions and millions of people, and the same is true with grip strength, its objective. It's easy to measure, but I think it as you said, I think it's a proxy for something bigger which is it's an overall proxy for muscle mass strength, things like that and and is the best way to develop grip strength hanging from a bar. No you're definitely not on Instagram or well how do we that's it? That's a test set so I'll do those sets to test its really carrying things. It's by far the best way so far more carries again, you know I get gripped.
Strength by deadlifting and doing other things as well. But I don't these are things that are all kind of secondary. What everybody should be doing is carrying this is our is the human superpower, right? Michael Easter writes about this in the comfort crisis, I think which is, there's no animal. Like we're pretty pathetic animals if you think about it, right? Like, you know, everything can run faster than a server short period of time. Swim faster, their pound-for-pound stronger, all this other stuff.
A couple things we do really well over 24 hours, we can cover pretty much more territory than any other land animal and we can carry far more weight up, right? Mmm, no one can know when I'm going to come close to Astrid. I never thought about that. Yeah, yeah, obviously a horse if you domesticate, it will carry more weight on its back, but yeah. Like it's not like a gorilla. Can carry more weight upright than weekend, like we were really but we were born apprising. I would think a gorilla could not for a long-distance know they're good. They're not, they don't have that stability, right? Like
We can, we can stand up and just carry things. So like it's not a big ask for a guy, our age to carry his body weight in his hands. Yeah, you know, half your body weight in each hand and be able to carry that for a minutes. Yeah, so farmer carries, that's the main thing. Yeah, I mean that's it later if you did nothing else, but that, that would be the most important thing. And then, of course, there's so many variations on these things. There's a billion threads, I could pull on exercise and nutrition with you, where we got to wrap.
Up this up at some point, but I don't want you to go without talking a little bit about this notion of healthy addictions. You just put up a blog post the other day about this and and this is something I've been thinking a lot about as it pertains to my own behaviour and habits of course. But also more generally the way that we can all sort of hide behind healthy addictions that Society, you know, Smiles upon or which, as I said earlier.
You know, make us successful, whether it's workaholism exercise addiction which I'd like to hear your thoughts on and also you know some of these nutrition protocols with fastening intermittent fasting, delayed eating all these sorts of things are ways to mask Eating Disorders or extreme diets etcetera. We can just say, well, I'm doing the carnivore diet or I'm doing, you know? I'm, I'm doing one meal a day or it's like actually have an eating disorder. That's what's really going on here. You're just doing what's trendy right now.
Now, or you know, whether it's training for an Ironman Endurance Sports, of course, like all of these things if you're, you know, prone to addictive behavior like I am, I can easily burrow into any number of these things and, you know, and and hide contentedly for for quite some time and I've done that.
You know, one of things, I think that's really interesting to ask, and I ask myself all the time, if you sure you've listened to it, I don't you. Listen to her recently, you know, the commencement speech by David Foster Wallace is water. Of course, one of my favorites. And so that was another thing. I'll tell you when I was really in the throes of early recovery, I probably listen to that once a week. I could almost recite It Off by heart and it really speaks to me. And one of the things that constantly sends chills up my spine, is when he talks about how we're all addicts.
Like where and he words it through religion. Like, we all have a God and he's, you know, he talks about how some people their God is the actual God. And he kind of believes the fact that they might be, they might be the lucky ones, but if your God is power, you're never going to be powerful enough. If your God is intelligence, you're always going to feel like a failure or a fraud. If your God is your body, you will die a thousand deaths before they actually bury you and I think that that goes back to kind of a question you asked earlier, which is
How do you take stock of where your emotional health is? I'll tell people go and listen to David Foster Wallace. Let's talk five times and go through it, like be honest. And look inwards when you hear that. Like, where is your god?
And don't say you don't have one. Right? Just because you're an atheist doesn't mean you don't have a God. And I think about this all the time. Like I think about how much did I worship my body and of course I still do to some extent and I think about how can I slowly start to let that go? Where can I release this tension between I place? Such a premium on my body that I'm doing all of these things take to take care of it. But at the same time,
I can't worship it so much that I'm unwilling to Let It Go as it goes. Mmm. And I think that's like the biggest challenge that I think I'm going to face in the next 50, whatever. How many years? I have left 30, 40 years, I don't know. But it's that it's the graceful aging part that says like you got to let go sometimes like you know do the best you can.
But don't do so much more that you ruin this experience of living.
And like you, it's hard to imagine how restrictive I used to be in my nutrition. It's insane. And in some ways like my nutrition today is so unrestrictive in some ways as a response to that. It probably looks pretty regimented to the ordinary person. But sure. I eat a bite of pretty healthy diet compared to the average American. I'm sure. But it's like I wouldn't if my kids make brownies like I wouldn't hesitate to eat three of them like I did like it's that it I'm not.
Strip in that way. What you're talking about involves threading a needle and doing a bit of a dance. Because on the one hand, like you have this whole thing about the centenarian decathlon, I want to win the sentence, like there's a drive there, there's a commitment, there's maybe, you know, even a little bit of an obsession and the personal growth comes in holding that Loosely, you can have something that you care about that you're working towards
Towards but which you also maintain some level of healthy distance from like that, that ability to be okay with where you're at and who you are while also working towards some type of self-improvement is a you know it's it's a weird kind of thing that you're trying to hold, right? Like it is water that you're trying to do you know that slipping through your fingers but I think the the key
To the whole thing. And I think you'll agree, is this, is this piece about self-love. If you hold yourself in healthy regard, then you can be okay with the natural progression of your own decline. A decline that you're trying to slowly arrest. And yet at some level are also at peace with
Yeah, I agree that that's that's the ultimate Challenge and if you if you don't have that healthy self-regard then you are going to be driven in an unhealthy way to achieve this other thing which you've convinced yourself will solve that problem
for you.
Yeah, I think that I guess that's one of the things that I even hesitate to use the word longevity sometimes because the way I think of it you have to spend a while explaining what it means and how it includes all these other things like you're talking about. Whereas for the most part, I think when you hear the word longevity, you think, immortality you think perfection?
And truthfully the first version of this book, that's what it was about. So why the book didn't come out? Yeah, these things happen when they're supposed to happen and there's a there's a, there's a spirituality in that Peter, right? Like you talk in the book a little bit about. What was the quote that you were exposed to when you when you first arrive? Oh yeah, religion is for whoever spirit is religion, is for people who are afraid of hell, spirituality is for people who have been there, right? So, so my immediate
Question to that and maybe we can end on this is, what is your spirituality look like, like, how has that impacted you? Or this recovery Journey that you've been on? Has that you know, LED you into a place of Greater openness and receptivity to things? Perhaps a bit more mystical.
I wish I could say yes, but but they're the truth of it is no, I think the biggest impact it has had on me which is probably some variation of spirituality is that. It's made me feel much less significant in the
universe.
I don't think, I think it's so much easier for me now to appreciate my irrelevance on this planet.
And that makes it easier for me to focus on the things that matter.
I you know when my wife met me she used to she made a t-shirt for me was I'll just it's a bit of a weird story but in residency, you know, we worked really hard. We work like 120 hours a week and I still in residency. Despite doing this was adamant that I like write this book about surgery.
And I would work on this thing with all my free time and it took like ears. And I it was basically, I'm sitting at a being a very small little book, but I had to read. I forget like,
19 Pages a day of surgical textbooks for three years and then summarize it and do it and I'm working on this nonsense and my wife was like, why are you doing this? And she's like well what's your legacy going to be like you got to have a legacy in this world and so one day she made me a t-shirt that was like what's your legacy or something is kind of mocking me and I just think like I think that's nonsense like I'm not gonna have a legacy. Like if I died tomorrow
Outside of my wife and my kids. Everyone will forget about me in 3 months.
And I used to like that thought like to fight against that used to be so much a part of my existence and I am so at peace with that. Now that I think that's the closest thing I can say to spirituality, which is, I was at Rick Rubin has a beautiful place in Italy, we were there with him last summer.
And it's a, it's an old place like but Rick is like the third person to own it in 500 years. Mmm and I was so moved by this place because I felt like it was the most irrelevant I've ever felt in a good way. And I remember thinking I would love to die here and be buried there so that the carbon nitrogen oxygen and me became a part of that Vineyard
And I know, I just think that that's to me, that's spirituality, it's just it's not Mystic, it's just appreciating the carbon cycle and knowing that we're all just kind of doing the best we can and not much more. I think there's pretty uninspiring there's no I think there is something, you know, quite beautiful and mystical built into that. There's of course this, you know, appreciation for impermanence and and and the humility that that
Ed's right. And I think embodying that you know sense of impermanence and and and humility allows you to more clearly. See and understand and appreciate the things that actually matter in the present, which are your relationships etcetera, and it divorces you from like the Legacy like that, that burning desire, that's driving you when that gets snuffed out or at least muted somewhat, you can then actually start living your life and stop running away from it.
Right, like you say, in the epilogue of the book that basically, this drive to understand Health span. And Longevity, was driven by this extreme fear of death, and a determination to have a lasting Legacy is born out of an unhealthy relationship with with death, right? And coming to terms with that and making peace. With that allows you to actually live your best life and ironically extend your house mannat lifespan in. So doing it right? I believe so, yeah. Yeah.
Beautiful man. Well, this was great. Probably a little different than some of the other podcast you're going to do. I if you want the tactics probably tune in to Tim Ferriss, who knows what you're going to do with with Andrew huberman, Rogan could go and any one of a million directions I suppose. But this was really special for me and and I appreciate you being. So, open and honest today and like I said at the outset, the work that you do is really important. It's meaningful to me. It's meaningful to Millions.
People and I commend you on your commitment to it. And actually, finally following through on this book, which is now going to be out in the world and which you ended up voicing yourself. Yes. After some consternation about your ability to read your own book. I'm really glad I got ya good. Glad I didn't have to do it under these circumstances but I'm really glad I did it. Yeah, good man. Well we certainly didn't cover all of it. We recovered maybe point zero zero zero one percent of it so perhaps I can
Joel you to come back and talk with me more. I'd love to see what you got to come out and spend some time at Austin with me as well. I would love to do that. Thank you Peter. Let's get your, get some tea and some ice or whatever you need on your voice, but we did it three hours, you made it through powered through that. That 74% that believed in you were correct. Cheers, thanks. Thanks, peace.
This episode was brought to you by inside tracker, learn how to live healthier longer by visiting. Inside tracker.com Rich, Roll, and use code, Rich, Roll at checkout to save, 20% off the entire store.
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