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#373 – Thyroid function and hypothyroidism: why current diagnosis and treatment fall short for many, and how new approaches are transforming care | Antonio Bianco, M.D., Ph.D.
Antonio Bianco is a world-renowned physician-scientist and expert in thyroid physiology and metabolism. In this episode, Antonio explores the complex biology of thyroid hormone production, conversion, and regulation—highlighting how deiodinase enzymes modulate hormone activity at the tissue level and why that matters for interpreting lab results. He discusses the shortcomings of relying solely on TSH as a marker of thyroid function, the ongoing debate around combination therapy with T3 and T4 versus standard T4 treatment, and how genetics, tissue sensitivity, and individual variability influence thyroid hormone metabolism. The conversation also examines how hypothyroidism affects energy, mood, cognition, and longevity; why some patients remain symptomatic despite "normal" labs; and how future research could reshape treatment paradigms.
We discuss:
How the thyroid produces, stores, and activates hormones like T4 and T3 to finely regulate thyroid activity [2:45];
How fasting alters thyroid hormones to conserve energy [12:45];
Action of the deiodinases: how D1, D2, and D3 enzymes control the activation and inactivation of thyroid hormones [19:15];
The normal function of thyroid hormone and the roles of the hypothalamus, pituitary gland, and deiodinases in maintaining hormonal balance [23:30];
Why understanding thyroid physiology is essential for proper diagnosis and treatment of hypothyroidism [33:45];
Testing for thyroid hormones: understanding free vs. total levels, the limitations of current T3 assays, best practices, and more [36:00];
Genetic and sex-based variability in thyroid hormone regulation and their limited clinical significance [43:45];
Hyperthyroidism: causes, symptoms, diagnosis, and treatment options [46:00];
Hypothyroidism: diagnosis and autoimmune causes of hypothyroidism [56:30];
More on hypothyroidism: diagnostic biomarkers, antibody patterns, and non-autoimmune presentations [1:05:00];
Thyroid hormone replacement therapy [1:15:15];
More on thyroid replacement strategies: exploring the evidence gaps, mortality signals, effects on lipids, and more [1:28:00];
Hypothyroidism basics: causes, antibody implications (including pregnancy), and how to make the diagnosis before choosing therapy [1:35:15];
Thyroid medication: compounded controlled-release T3, brand name versus generic, and what Antonio prescribes to newly diagnosed hypothyroid patients [1:42:45];
Redefining treatment success: why normalizing TSH isn't always enough for patients with hypothyroidism [1:54:45];
Case studies: analysis of two unusual cases of thyroid disease [1:57:00];
Dangers of supplementing with high levels of iodine, and female-specific risk of thyroid disease [2:05:45];
Case study of a patient who presents with elevated TSH but no symptoms [2:09:30];
How future research could reshape treatment, and Antonio's new book called "Rethinking Hypothyroidism" [2:13:15]; and
In this "Ask Me Anything" (AMA) episode, Peter breaks down the science of dietary fiber, moving beyond the blanket advice to "eat more fiber" to uncover what it actually does in the body and where its benefits are truly supported by evidence. He explains how different types of fiber—soluble, insoluble, viscous, and fermentable—affect digestion, satiety, weight management, and glycemic control, and compares their impact to other, more potent metabolic tools. Peter also examines how certain fibers influence lipid metabolism and cardiovascular risk, evaluates the strength of evidence for fiber's role in colorectal cancer prevention, and highlights why some individuals may not tolerate specific fibers well. The discussion concludes with practical guidance on moving past generic fiber targets toward a more strategic and personalized approach that maximizes the true benefits of fiber.
If you're not a subscriber and are listening on a podcast player, you'll only be able to hear a preview of the AMA. If you're a subscriber, you can now listen to this full episode on your private RSS feed or our website at the AMA #77 show notes page. If you are not a subscriber, you can learn more about the subscriber benefits here.
We discuss:
Why it's time to re-examine the evidence behind dietary fiber recommendations [2:00];
Why it's hard to isolate fiber's true effects on health: the limits of nutritional epidemiology [5:45];
Defining dietary fiber: what it is, how it's digested, and why different types have different effects [8:15];
Understanding fiber properties: how solubility, viscosity, and fermentability shape its effects in the body [11:15];
Resistant starches explained: types, food sources, and how cooking and cooling influence their benefits [16:30];
A framework for evaluating each of the major health claims linked to fiber [19:15];
How fiber can support weight loss: mechanisms, realistic expectations, and its complementary role to broader dietary strategies [20:30];
How fiber modestly improves glycemic control by reducing glucose spikes and insulin demand [26:15];
How fiber modestly lowers LDL cholesterol and supports cardiovascular health [34:30];
How fiber compares to other available tools and strategies for managing lipids, blood sugar, and weight [42:00];
Fiber's role in colon cancer prevention: mechanisms, evidence, and limitations [45:30];
Is fiber necessary for colon cancer prevention in otherwise healthy individuals? [53:30];
Why some people have adverse reactions to certain types of fiber, and how to manage them [56:00];
A general strategy for dietary fiber: combine multiple fiber types through whole foods and supplements [58:45];
Why total fiber intake is more important than the ratio of soluble-to-insoluble fiber [1:02:45];
The optimal timing and context for consuming fiber to maximize blood sugar control and metabolic benefits [1:05:00];
How food processing affects the functional properties of fiber, the differences between supplement forms and natural sources, and why whole foods generally remain the best option [1:06:45];
Fiber's potential to interfere with medication absorption [1:09:30];
How to safely increase fiber intake: ramp up gradually and stay hydrated [1:12:00];
Final takeaway on fiber: modest benefits, strong rationale, low downside [1:13:00];
Peter's carve-out: lessons and inspiration from the Acquired podcast [1:14:30]; and
In this "Ask Me Anything" (AMA) episode, Peter explores how to determine the right diet for yourself rather than searching for a universal "best" diet. He begins by laying out five non-negotiable criteria that any sustainable eating pattern must meet—energy balance, metabolic health, adequate protein, micronutrient sufficiency, and long-term adherence—before introducing a practical rubric for evaluating different diets. Using this framework, Peter walks through the ketogenic, carnivore, vegan, and Mediterranean diets, highlighting their strengths, ideal candidates for each, and common pitfalls such as micronutrient gaps or adherence challenges. He explains why this guidance is aimed at people who feel overwhelmed by diet choices, not zealots defending a single approach, and provides practical advice on using tools like DEXA scans, lab markers, continuous glucose monitors, and symptom tracking to assess whether a diet is truly working.
If you're not a subscriber and are listening on a podcast player, you'll only be able to hear a preview of the AMA. If you're a subscriber, you can now listen to this full episode on your private RSS feed or our website at the AMA #75 show notes page. If you are not a subscriber, you can learn more about the subscriber benefits here.
We discuss:
Peter's family chess battle [3:00];
Framing the diet discussion: moving past tribalism to practical frameworks for evaluating various dietary strategies [5:00];
Peter's high-level nutrition framework [11:00];
Why diet is such a uniquely polarizing subject [14:15];
The five non-negotiables that apply to any diet [17:45];
How to think about energy balance in the context of evaluating a specific diet [20:15];
How diet can address metabolic health [21:45];
Protein as a dietary foundation [23:30];
Micronutrient essentials: avoiding deficiencies in restrictive and processed diets [24:45];
Why adherence and sustainability are essential for diet success [27:15];
Examining the standard American diet through the five non-negotiables [31:00];
The evaluation framework for specific diets [33:30];
The ketogenic diet: defining ketosis, clinical origins, modern uses, and potential health benefits [35:00];
The main strengths and weaknesses of the ketogenic diet [43:00];
How to avoid micronutrient deficiencies while on a ketogenic diet [47:15];
Electrolytes and fiber and the ketogenic diet: preventing magnesium loss and maintaining digestive health [49:15];
Adherence challenges of the ketogenic diet [51:30];
The carnivore diet: definition, motivations, anecdotal benefits, and possible mechanisms [53:15];
The main strengths and weaknesses of the carnivore diet [57:30];
Plant exclusion on the carnivore diet: nutrient gaps, gut changes, and unanswered questions [1:03:15];
Adherence challenges of the carnivore diet [1:04:45];
The vegan diet: definition, core beliefs, and various motivations for this strategy [1:05:45];
The main strengths and weaknesses of the vegan diet [1:09:15];
Adherence to the vegan diet: social acceptance, edge cases, and personal sustainability [1:13:15];
The Mediterranean diet: definitional challenges, traditional patterns, and its relatively strong evidence base [1:15:15];
Limitations of the Mediterranean diet: loose definitions and indulgence risks [1:19:30];
In this "Ask Me Anything" (AMA) episode, Peter tackles essential questions about magnesium, beginning with the important roles it plays in the body and why maintaining proper levels is crucial. Peter discusses the harms of magnesium deficiency, how to determine if you're deficient, potential causes of deficiency, and how diet and supplementation can be used to increase magnesium levels. Peter unravels the confusion surrounding magnesium supplementation, discussing the optimal forms and recommended daily intake while addressing concerns about excess consumption. He also explores the potential cognitive and sleep benefits associated with magnesium supplementation. Finally, Peter concludes with a look into his recent experimentation with new exercises to serve as benchmarks to assess his progress and fitness levels as he navigates the aging process.
If you're not a subscriber and are listening on a podcast player, you'll only be able to hear a preview of the AMA. If you're a subscriber, you can now listen to this full episode on your private RSS feed or our website at the AMA #54 show notes page. If you are not a subscriber, you can learn more about the subscriber benefits here.
We discuss:
The important roles of magnesium in the body [2:45];
How to determine if you might be deficient in magnesium [10:15];
Addressing migraines related to low magnesium [14:45];
The prevalence of magnesium deficiency [16:30];
Various conditions and drugs that can negatively impact magnesium levels [21:30];
Magnesium-rich foods and factors that impact absorption of magnesium [24:30];
Daily targets for magnesium supplementation and whether it's possible to take too much [30:15];
The different forms of supplemental magnesium [34:00];
How absorption of magnesium from food compares to absorption from supplements [36:15];
Choosing the right magnesium supplements for optimal absorption [37:15];
The unique ability of magnesium L-threonate to increase brain magnesium concentration [40:15];
Potential cognitive benefits of magnesium [43:00];
Potential sleep benefits of magnesium [48:45];
Takeaways on magnesium and a look into Peter's personal protocol [53:15];
Peter's new benchmarks related to exercise and age [58:30]; and
The potential impact of hearing loss on brain health and neurodegeneration [2:04:30]; and
Richard Miller is a professor of pathology and the Director of the Center for Aging Research at the University of Michigan, as well as a previous guest on The Drive. In this episode, Rich provides an update on the exciting work of the Interventions Testing Program (ITP), an initiative designed to assess potential life-extending interventions in mice. Rich covers the notable successes like rapamycin, 17⍺-estradiol, and acarbose as well as notable failures like nicotinamide riboside, metformin, and resveratrol, providing valuable lessons about the intricacies of the aging process. Rich delves deep into aging biomarkers and aging rate indicators, unraveling crucial insights into the science of geroprotective molecules. Additionally, Rich discusses some surprising successes of recent molecules tested by the ITP and concludes with an optimistic look at future frontiers, including bridging the gap from mice to humans.
We discuss:
An overview of the Interventions Testing Program (ITP) [3:45];
How the mice used by the ITP are superior for research relative to mouse models used in most research [11:15];
Design of ITP studies, outcomes tested, and metrics of interest [19:00];
The process and challenges of drug formulation for mice [30:00];
Four drugs identified by the ITP that extends the lifespan of mice [36:30];
The success of rapamycin and what it tells us about the biology of aging [43:15];
Other measures of healthspan evaluated by the ITP in stage 2 studies [50:45];
Distinguishing aging rate indicators from biomarkers of aging [57:30];
Aging rate indicators identified through the examination of slow-aging mice [59:15];
Why proteomics are essential to understand changes in the cell [1:12:15];
Unraveling aging rate indicators: dose-effect, duration, and future frontiers [1:21:45];
A closer look at aging rate indicators: bridging the gap from mice to humans [1:27:00];
What do laboratory mice die from? [1:38:45];
Distinguishing between a drug that improves an age-sensitive outcome and a drug that improves all aspects of aging [1:42:00];
The ITP study of 17⍺-estradiol: mechanisms of life extension and surprising sex differences [1:43:30];
Unsuccessful drugs studied by the ITP: resveratrol, metformin, and nicotinamide riboside [1:51:30];
Over-the-counter successes in the ITP: meclizine and astaxanthin [2:01:00];
A senolytic drug, fisetin, fails to extend lifespan [2:07:00];
Can targeting senescent cells slow aging? [2:13:00];
Arthur Brooks is a social scientist, professor at Harvard University, columnist for The Atlantic, and bestselling author. In this episode, Arthur returns to the podcast to discuss his new book, Build the Life You Want. He delves into the nuanced concept of happiness, differentiating between momentary feelings and overall wellbeing. He explains the importance of understanding one's personality pattern with respect to positive and negative emotions in order to better self-manage emotions. He delves into the three key elements of happiness, offering practical strategies for enhancing those specific domains through methods such as metacognition, transcendent experiences, discipline, minimizing self-focus while directing attention outward, and more. Through personal examples, Arthur demonstrates that one can actively track well-being levels and take intentional steps to cultivate happiness and enhance overall well-being.
We discuss:
Happiness vs. happy feelings, and how happiness and unhappiness can coexist [4:30];
The six fundamental emotions [8:00];
The evolution and heritability of happiness, and the four personality patterns with respect to positive and negative emotions [17:30];
Navigating relationships: the power of complementarity over compatibility [23:30];
The importance of self-managing your mental habits [25:30];
Enjoyment: one of the three macronutrients of happiness [32:00];
Satisfaction: one of the three macronutrients of happiness [43:45];
The reverse bucket list, metacognition, and other techniques to protect yourself from your limbic system [51:00];
Meaning: one of the three macronutrients of happiness [57:30];
The four quarters of your life and how that relates to the meaning of your life [1:05:00];
Putting metacognition into practice [1:09:00];
What might explain the societal downdrift in happiness over the last few decades? [1:17:00];
Taking charge of your happiness: discipline, transcendent experiences, and other deliberate actions for happiness [1:30:30];
Tracking happiness: biomarkers and micronutrients behind the macronutrients of happiness [1:42:00];
The value in minimizing the self and looking outward [1:49:45];
How Arthur surprised himself with his ability to improve his happiness [1:54:00]; and
To support Tom's mission and work, please visit: https://africanmissionhealthcare.org/donation/catena/.
In this episode, Tom Catena, a missionary physician who runs Mother of Mercy Hospital in the Nuba Mountains in Sudan, describes some of his extraordinary work as the only doctor in a remote, war-torn region of Africa. In terms of individual lives saved, you could argue that there is no other person on the front lines doing more than Tom. Additionally, we explore the manner in which the Nuba people die, which is in striking contrast to the ubiquity of chronic disease and self-harm in the West, despite the extreme poverty and unimaginable suffering experienced by the Nuba people. Lastly, we discuss the lessons to be gleaned from the Nuba people, who, despite their suffering, live so harmoniously, happily, and resiliently.
We discuss:
Background, medical training, and early days of missionary work in Africa [5:15];
Tom arrives at Mother of Mercy Hospital in the Nuba Mountains of Sudan, civil war breaks out, and his staff evacuates [12:30];
Learning surgery on the job and earning the trust of the community [37:00];
The amazing people of Nuba, and why Nuba feels like home to Tom [47:45];
NY Times article about Tom's work, and Tom's new venture on the board of the Aurora Prize Foundation, raising awareness and funds for other missionaries [59:45];
Tom's mind-blowing ability to deal with chaos while seeing hundreds of patients per day [1:12:00];
The most afraid Tom has ever been, and how he copes with the emotional trauma of his daily experiences [1:19:45];
The basic tools, technologies, and medicines that Tom is lacking that could save many lives [1:30:00];
The logistical challenge of helping Tom's hospital, and what Tom really needs [1:35:15];
Diseases in the adult population [1:38:30];
Living without possessions, finding meaning, and being a missionary [1:55:45];
Happiness, sense of purpose, and suicide: contrasting the US with Nuba [2:07:15];
Other than donations, is there a way people can help Tom and other similar causes? [2:15:15];
The food in Nuba [2:18:30];
Tom's annual bout of malaria [2:23:45];
Patients Tom will never forget [2:26:00];
Resources for people wanting to get involved in helping Tom's work [2:31:00];
Peter tells a story that defines Tom [2:32:00]; and
In this "Ask Me Anything" (AMA) episode, Peter explores various pharmacologic tools commonly utilized to improve metabolic health and treat diabetes, including SGLT-2 inhibitors, metformin, and GLP-1 agonists. He examines the available data on these drugs, assessing their comparative effectiveness and their potential in the context of lifestyle interventions. Additionally, he offers insights into whether SGLT2 inhibitors hold promise as geroprotective agents beyond their effects on glycemic control. Next, Peter analyzes the relationship between statin usage and the risk of developing insulin resistance and type 2 diabetes, investigating possible causal pathways and providing insights into strategies for risk reduction. He offers insights on monitoring adverse statin effects and evaluating the need for adjustments, ultimately weighing the trade-off between the risk to overall metabolic health against the benefits of reducing apoB levels through statin use.
If you're not a subscriber and are listening on a podcast player, you'll only be able to hear a preview of the AMA. If you're a subscriber, you can now listen to this full episode on your private RSS feed or our website at the AMA #53 show notes page. If you are not a subscriber, you can learn more about the subscriber benefits here.
We discuss:
Pharmacologic tools for improving metabolic health, and the relationship between statins and insulin resistance [2:00];
SGLT-2 inhibitors: how they work and help to manage type 2 diabetes [4:15];
The history of SGLT2 inhibitors – from discovery to the current state [10:15];
Comparing the various FDA-approved SGLT2 inhibitors [15:00];
Other beneficial effects of SGLT2 inhibitors outside of glycemic control [20:15];
Exploring SGLT2 inhibitors as potential geroprotective molecules [22:45];
The side effects and risks associated with SGLT2 inhibitors [31:45];
Medications, lifestyle interventions, and other considerations for treating diabetes and improving metabolic health [37:45];
Metformin as a tool for pre-diabetics, and how metformin compares to lifestyle interventions [44:00];
How GLP-1 agonists compare to metformin and SGLT2 inhibitors in terms of glycemic control and weight loss [49:15];
Exploring the relationship between statin use and the risk of developing insulin resistance and type 2 diabetes [52:30];
Possible mechanisms of statin-induced insulin resistance and diabetes, and potential mitigation strategies [1:04:30];
How to monitor for adverse effects of statin use and assess the need for adjustments [1:11:45];
Weighing the benefits and risks of statin use: does the diabetes risk outweigh the benefits of lowering apoB with a statin? [1:15:30];
Harold (Hal) Burstein is an internationally renowned breast cancer expert. In this episode, Hal discusses a broad range of topics related to breast cancer, starting with the intricacies of breast anatomy and the endocrinological factors at play. He covers the spectrum of breast cancer, from precancerous lesions to invasive breast cancer, classifying these conditions into a helpful framework. He delves into various screening methods, including self-exams, mammograms, ultrasounds, and MRIs, and addresses the ongoing debate surrounding early screening and detection. Hal provides insights into the latest advancements in cancer treatment, offering valuable guidance for individuals to understand their unique circumstances within the three primary categories of breast cancer. Finally, Hal delves into the role of genetics in breast cancer and brings attention to the less commonly addressed issue of male breast cancer.
We discuss:
The prevalence and mortality rate of breast cancer in women [4:15];
The anatomy of the breast and the complex factors behind breast cancer development [6:30];
The three main categories of breast cancer [16:45];
Breast cancer risk: the impact of menopause, estrogen, breast density, obesity, and more [21:15];
Finding and evaluating lumps in the breast [25:30];
Identifying and treating precancerous lesions like ductal carcinoma in situ (DCIS) [31:00];
Post-lumpectomy for DCIS: standard of care, future risk of cancer, and pros and cons of radiation and other preventative options [41:15];
Lobular carcinoma in situ (LCIS): how it differs from DCIS in terms of treatment and future risk of invasive cancer [55:00];
Breast cancer screening: mammography, ultrasound, MRI, and more [1:03:45];
Invasive breast cancer: pathology report, surgery, and survival [1:11:00];
The argument for aggressive screening for breast cancer [1:22:15];
Advances in the treatment of breast cancer, adjuvant therapy, and neoadjuvant therapy [1:27:00];
The use of hormone replacement therapy in women who are in remission from breast cancer [1:41:15];
The role of genetics in breast cancer [1:44:45];
The importance of multidisciplinary care delivered by cancer centers [1:53:15];
Kari Nadeau is a physician scientist with expertise in treating food allergies. In this episode, Kari first explains the fascinating workings of the immune system, exploring how it adeptly defends against bacteria and viruses but how the same system can lead to food allergies. She proceeds to explore the complexities of food allergies, detailing their typical developmental patterns, underscoring the significance of preventative approaches like early exposure, and highlighting the potentially life-threatening nature of severe food allergies. Kari illuminates the latest advancements in immunotherapies that not only mitigate allergy severity but also hold the potential to completely cure the patient. Additionally, Kari shares her concerns about the increasing levels of air pollution, elucidating its adverse effects on health while providing valuable suggestions for reducing exposure.
We discuss:
Kari's motivation to study food allergies [4:00];
Overview of the immune system and the family of immunoglobulins [9:00];
How our immune system fights viruses, bacteria, or fungi, and some exceptions to the rule [13:00];
Why our immune system is generally better at fighting viruses than bacterial infections [18:45];
Differentiating a food sensitivity from a food allergy, and a discussion about celiac disease [25:30];
How food allergies develop, why they can be lethal, and factors contributing to the uptrend in food allergies [35:45];
The role of environmental factors in the onset of food allergies and strategies for prevention [50:15];
How immunotherapy helps to overcome, and even cure, food allergies [1:04:15];
Can immunotherapy work for environmental allergens like pollen? [1:24:00];
Air pollution: impact on health and tips for reducing your risk [1:25:30];
Resources for those wanting to learn more or find clinical trials related to food allergies [1:40:45]; and
In this special episode of The Drive, Peter discusses a variety of topics, breaking away from the typical deep-dive format to explore a wide range of common questions submitted by listeners. Peter tackles subjects like the viability of living to 120 and beyond, addressing some of the optimistic theories regarding achievement of this remarkable feat. Peter then shares his drug and supplement regimen while emphasizing how individualized these protocols need to be. The conversation also touches on lowering apoB, the long-term use of statins, the myth of good vs. bad cholesterol, the complexities of nutrition research, the quest for the ideal diet, and Peter's strategies for hitting daily protein goals. Peter finishes with a discussion about his favorite health-tracking wearables, the role of CGM in non-diabetics, and more.
We discuss:
Overview of topics and previous episodes of a similar format [2:45];
The viability of living to 120 and beyond: some optimistic theories [4:45];
The potential of mTOR inhibition as a mid-life intervention, and longevity potential for the next generation [13:30];
A framework for thinking about geroprotective drugs and supplements in the context of a lack of aging biomarkers [17:00];
Supplements Peter takes and how his regimen has changed in the last year [26:15];
Pharmacologic strategies to lower ASCVD risk, the limitations of statins, nutritional interventions, and more [36:15];
Misnomers about cholesterol [48:00];
Why nutritional research is so challenging, some general principles of nutrition, and why Peter stopped doing prolonged fasts [50:45];
Optimizing protein intake [59:45];
Wearables for sleep and exercise, continuous glucose monitors (CGM), and a continuous blood pressure monitor on the horizon [1:04:45]; and
In this "Ask Me Anything" (AMA) episode, the discussion zeroed in on the practical application of hormone replacement therapy in women. Peter walks through the signs, symptoms, and hormonal changes in women approaching – and going through – menopause. He provides an overview of the FDA-approved HRT formulations and explains how women might go about choosing the right option for themselves. Peter also describes the significant changes in testosterone levels in women over time and the options, as well as the considerations and challenges of testosterone replacement therapy (TRT) for women. Lastly, Peter highlights the necessary role of compounding pharmacies in HRT, underscores concerns regarding the quality and sterility of compounded drugs, and offers guidance on locating a trustworthy pharmacy.
If you're not a subscriber and are listening on a podcast player, you'll only be able to hear a preview of the AMA. If you're a subscriber, you can now listen to this full episode on your private RSS feed or our website at the AMA #52 show notes page. If you are not a subscriber, you can learn more about the subscriber benefits here.
We discuss:
Why hormone replacement therapy is such an important topic [2:00];
The onset of menopause: symptoms, blood tests, and when to consider HRT [6:00];
Tests that may provide indications of perimenopause and their implications for fertility [9:15];
Vasomotor symptoms: hormonal changes that cause hot flashes/night sweats, and HRT therapies that can help [13:45];
The role of estrogen in menopausal HRT [17:30];
The limited role of progesterone in HRT protocols [25:15];
What is a "bioidentical" hormone? [28:30];
Overview of the FDA-approved HRT formulations [31:45];
Determining HRT dosing and considerations for perimenopausal women [37:45];
Choosing the right HRT formulation: pros and cons [43:30];
Examining the link between certain forms of estrogen and breast cancer [46:45];
Changes in testosterone levels in women over time and why it matters [50:00];
Recognizing low testosterone in women: common symptoms and diagnosis [53:45];
Testosterone replacement therapy for women: options, considerations, and challenges [57:30];
The long-term use of testosterone in women: examining the limited data [1:00:15];
What is a compounding pharmacy? [1:09:30];
Reasons to opt for a compounding pharmacy over a pharmacy that adheres to stricter regulations [1:16:00];
The tragic incidents that heightened concerns about compounding pharmacies [1:20:45];
Tips for finding a reputable compounding pharmacy [1:27:45]; and
#363 ‒ A new frontier in neurosurgery: restoring brain function with brain-computer interfaces, advancing glioblastoma care, and new hope for devastating brain diseases | Edward Chang, M.D.
Edward Chang is a neurosurgeon, scientist, and a pioneering leader in functional neurosurgery and brain-computer interface technology, whose work spans the operating room, the research lab, and the engineering bench to restore speech and movement for patients who have lost these capabilities. In this episode, Edward explains the evolution of modern neurosurgery and its dramatic reduction in collateral damage, the experience of awake brain surgery, real-time mapping to protect critical functions, and the split-second decisions surgeons make. He also discusses breakthroughs in brain-computer interfaces and functional electrical stimulation systems, strategies for improving outcomes in glioblastoma, and his vision for slimmer, safer implants that could turn devastating conditions like ALS, spinal cord injury, and aggressive brain tumors into more manageable chronic illnesses.
We discuss:
The evolution of neurosurgery and the shift toward minimally invasive techniques [2:30];
Glioblastomas: biology, current treatments, and emerging strategies to overcome its challenges [10:45];
How brain mapping has advanced from preserving function during surgery to revealing how neurons encode language and cognition [16:30];
How awake brain surgery is performed [22:00];
How brain redundancy and plasticity allow some regions to be safely resected, the role of the corpus callosum in epilepsy surgery, and the clinical and philosophical implications of disconnecting the hemispheres [26:15];
How neural engineering may restore lost functions in neurodegenerative disease, how thought mapping varies across individuals, and how sensory decline contributes to cognitive aging [39:15];
Brain–computer interfaces explained: EEG vs. ECoG vs. single-cell electrodes and their trade-offs [48:30];
Edward's clinical trial using ECoG to restore speech to a stroke patient [1:01:00];
How a stroke patient regained speech through brain–computer interfaces: training, AI decoding, and the path to scalable technology [1:10:45];
Using brain-computer interfaces to restore breathing, movement, and broader function in ALS patients [1:28:15];
The 2030 outlook for brain–computer interfaces [1:34:00];
The potential of stem cell and cell-based therapies for regenerating lost brain function [1:38:00];
Edward's vision for how neurosurgery and treatments for glioblastoma, Parkinson's disease, and Alzheimer's disease may evolve by 2040 [1:42:15];
The rare but dangerous risk of vertebral artery dissections from chiropractic neck adjustments and high-velocity movements [1:44:45];
How Harvey Cushing might view modern neurosurgery, and how the field has shifted from damage avoidance to unlocking the brain's functions [1:46:15]; and
Ted Schaeffer is an internationally recognized urologist who specializes in prostate cancer. In this episode, Ted delves deep into the realm of prostate health, starting with strategies for vigilance and effective management of the issues that can arise with aging, including urinary symptoms, prostatitis, pelvic pain, and prostate inflammation. Ted sheds light on the popular drug finasteride, renowned for its dual purpose in prostate shrinkage and hair loss prevention, as well as the contentious topic of post-finasteride syndrome. Ted then shifts to the topic of cancer, explaining how androgens, genetics, and non-genetic factors contribute to the pathogenesis of prostate cancer. He provides valuable insights into cancer screening, examining blood-based screening tools like PSA and the use of MRI in facilitating biopsies and their interpretation. Finally, he explores the various treatment options for prostate cancer, including surgical interventions, androgen deprivation therapy, and more.
We discuss:
Changes to the prostate with age and problems that can develop [3:45];
Behavioral modifications to help manage nocturnal urinary frequency and other lower urinary tract symptoms [8:30];
Pharmacologic tools for treating nocturnal urinary frequency and lower urinary tract symptoms [16:30];
Surgical tools for treating symptoms of the lower urinary tract [26:15];
HoLEP surgery for reducing prostate size [32:30];
Prostate size: correlation with cancer and considerations for small prostates with persistent symptoms [40:30];
Prostatitis due to infection: symptoms, pathogenesis, and treatment [46:45];
Prostatitis caused by factors besides infection [58:45];
How to minimize risk of urosepsis in patients with Alzheimer's disease [1:05:00];
Prostate cancer: 5-alpha reductase inhibitors, how androgens factor into pathogenesis, and more [1:10:00];
Post-finasteride syndrome [1:18:15];
The relationship between testosterone and DHT and the development of prostate cancer over a man's lifetime [1:26:30];
How genetic analysis of a tumor can indicate the aggressiveness of cancer [1:35:15];
Pathogenesis and genetic risk factors of prostate cancer and the use of PSA to screen for cancer [1:37:45];
Non-genetic risk factors for prostate cancer [1:45:45];
Deep dive into PSA as a screening tool: what is PSA, definition of terms, and how to interpret results [1:56:30];
MRI as a secondary screening tool and the prostate biopsy options [2:13:15];
Ted's ongoing randomized trial comparing different methods of prostate biopsy [2:24:00];
Determining when a biopsy is necessary, interpreting results, explaining Gleason score, and more [2:27:00];
Implications of a Gleason score of 7 or higher [2:46:45];
Metastasis of prostate cancer to different body locations, treatment options, staging, and considerations for patients' quality of life and survival [2:53:30];
How prostate cancer surgery has improved [3:09:30];;
Questions to ask your neurologist if you are considering prostatectomy for cancer [3:21:45]; and
#272 ‒ Rapamycin: potential longevity benefits, surge in popularity, unanswered questions, and more | David Sabatini, M.D., Ph.D. and Matt Kaeberlein, Ph.D.
In this episode of The Drive, Peter welcomes guests David Sabatini and Matt Kaeberlein, two world-leading experts on rapamycin and mTOR. David and Matt begin by telling the fascinating story of the discovery of rapamycin and its brief history as a pharmacological agent in humans. They then unravel the function of mTOR, a central regulator of numerous biological processes, and they discuss the pathways through which rapamycin exerts its potential benefits on lifespan. They touch upon initial studies that suggested rapamycin may have geroprotective effects and the ongoing research that continues to shed light on this unique molecule. Furthermore, they discuss the elusive details surrounding the frequency and dosing of rapamycin use in humans, and Peter emphasizes his reservations about indiscriminately prescribing rapamycin as a longevity drug for patients.
We discuss:
David and Matt's expertise in mTOR and rapamycin [3:00];
The discovery of rapamycin and its first use in humans as an immunosuppressant [13:15];
The emergence of rapamycin as a molecule with the potential to prolong lifespan [19:30];
The groundbreaking rapamycin study on mouse lifespan extension and the open questions about the timing and frequency of dosing [26:00];
Explaining mTOR and the biology behind rapamycin's effects [35:30];
Differences in how rapamycin inhibits mTOR complex 1 (MTORC1) versus mTOR complex 2 (MTORC2) [45:15];
Reconciling the biochemical mechanism of rapamycin with its longevity benefit [49:15];
Important discoveries about the interplay of amino acids (leucine in particular) and mTOR [54:15];
Reconciling rapamycin-mediated mTOR inhibition with mTOR's significance in building and maintaining muscle [1:01:30];
Unanswered questions around the tissue specificity of rapamycin [1:08:30];
What we know about rapamycin's ability to cross the blood-brain barrier and its potential impacts on brain health and neurodegeneration [1:13:45];
Rapamycin may act as an immune modulator in addition to immunosuppressive effects [1:21:30];
Might rapamycin induce changes in T cell methylation patterns, potentially reversing biological aging? [1:34:15];
Rapamycin side effects and impacts on mental health: fascinating results of Matt's survey on off-label rapamycin use [1:42:00];
The impact of taking rapamycin in people who contracted COVID-19: more insights from Matt's survey [1:51:15];
What David would like to study with mTOR inhibitors [1:54:45];
Joan Mannick's studies of RTB101 and other ATP-competitive inhibitors of mTOR [2:00:30];
The impact of mTOR inhibition on autophagy and inflammation and a discussion of biomarkers [2:10:00];
The Dog Aging Project: what we've learned and what's to come from testing rapamycin in companion dogs [2:17:30];
Preliminary results of primate studies with rapamycin [2:24:45];
Dosing of rapamycin [2:27:45];
The effect of rapamycin on fertility [2:36:45];
The outlook for future research of rapamycin and the development of rapalogs [2:39:00]; and
In this "Ask Me Anything" (AMA) episode, Peter dives deep into the critical topic of metabolic disease. He first sheds light on how poor metabolic health drives up the risk of developing other chronic diseases such as cardiovascular disease, cancer, neurodegenerative disease, and overall mortality. He explores the array of metrics and tests used to assess metabolic health, underscoring his preferred methodologies utilized with patients. Finally, Peter provides an overview of the factors one can manipulate in order to improve metabolic health.
If you're not a subscriber and are listening on a podcast player, you'll only be able to hear a preview of the AMA. If you're a subscriber, you can now listen to this full episode on your private RSS feed or our website at the AMA #51 show notes page. If you are not a subscriber, you can learn more about the subscriber benefits here.
We discuss:
Importance of metabolic health and a primer on metabolic disease [1:30];
How poor metabolic health increases one's risk for other chronic diseases [6:00];
How useful is body weight and BMI for estimating metabolic health? [9:45];
Overview of various tests and metrics used to understand metabolic health [12:15];
Traditional biomarkers and how Peter's point of view may differ from the guidelines [15:00];
Lactate: insights into metabolic health through fasting and resting lactate levels [17:00];
Zone 2 output: an important functional test of metabolic health [20:00];
Cardiopulmonary exercise testing (CPET) [25:45];
Visceral adipose tissue (VAT): what is VAT and how does it impact health? [27:00];
Oral glucose tolerance test (OGTT): how it works and why it is such an important metric for assessing metabolic health [32:15];
The utility of a continuous glucose monitor (CGM) [40:45];
Liver function and NAFLD [42:15];
Sleep as an intervention [46:00];
Exercise as an intervention [53:15];
Diet and nutrition [59:00];
How reducing stress can improve metabolic health [1:05:15]; and
Andrew Huberman, Professor of Neurobiology at Stanford University and host of the Huberman Lab podcast joins us in a special journal club episode. Peter and Andrew each present a recent paper that sparked their interests, delving into the findings, dissecting their significance, discussing potential confounders and limitations, and exploring remaining questions. Importantly, they share their methodologies for comprehending research studies, providing valuable insights for listeners to navigate this process independently. Peter presents an epidemiological study reevaluating a noteworthy metformin result that intrigued the anti-aging community, leading to discussions on metformin's geroprotective potential (or lack thereof) and the current lack of aging biomarkers. Andrew introduces a paper examining how our beliefs about the medications we take influence their biological effects, distinguishing the "belief effect" from a placebo effect and highlighting its exciting implications for the future.
We discuss:
The motivation behind this journal club conversation [2:45];
Why Peter chose a paper on metformin, how metformin works, and why it generated excitement as a longevity-enhancing agent [9:00];
Defining insulin resistance and its underlying causes [16:15];
Metformin as a first-line treatment for type 2 diabetes, and Peter's evolving interest in metformin as a geroprotective drug [22:00];
Defining the term "geroprotection" [24:45];
The 2014 study that got the anti-aging community interested in metformin [26:00];
Peter presents the 2022 paper that repeats the analytical approach from the 2014 Bannister study [33:15];
Greater mortality in the metformin group: how results differed between the 2022 paper and the 2014 paper [40:00];
This special episode is a rebroadcast of AMA #30, now made available to everyone, in which Peter and Bob Kaplan dive deep into all things related to studying studies to help one sift through the noise to find the signal. They define various types of studies, how a study progresses from idea to execution, and how to identify study strengths and limitations. They explain how clinical trials work, as well as biases and common pitfalls to watch out for. They dig into key factors that contribute to the rigor (or lack thereof) of an experiment, and they discuss how to measure effect size, differentiate relative risk from absolute risk, and what it really means when a study is statistically significant. Finally, Peter lays out his personal process when reading through scientific papers.
We discuss:
The ever-changing landscape of scientific literature [2:30];
The process for a study to progress from idea to design to execution [5:00];
Various types of studies and how they differ [8:00];
The different phases of clinical trials [19:45];
Observational studies and the potential for bias [27:00];
Experimental studies: randomization, blinding, and other factors that make or break a study [44:30];
Power, p-values, and statistical significance [56:45];
Measuring effect size: relative risk vs. absolute risk, hazard ratios, and "number needed to treat" [1:08:15];
How to interpret confidence intervals [1:18:00];
Why a study might be stopped before its completion [1:24:00];
Why only a fraction of studies are ever published and how to combat publication bias [1:32:00];
Frequency of training for Olympic weightlifting [1:22:15];
How post-activation potentiation (and the opposite) can improve power training and speed training [1:24:30];
The Strongman competition: more breadth of movement, strength, and stamina [1:32:00];
Why certain journals are more respected than others [1:41:00];
Peter's process when reading a scientific paper [1:44:15]; and
Wendy Chung is a board-certified clinical and molecular geneticist with more than 25 years of experience in human genetic disease research. In this episode, Wendy delves deep into the world of genetics by first exploring the historical landscape of genetics prior to decoding the human genome, contrasting it with what we know today thanks to whole genome and exome sequencing. She provides an overview of genetic testing by differentiating between various genetic tests such as direct-to-consumer, clinical, whole genome sequencing, and more. Additionally, Wendy unravels the genetic underpinnings of conditions such as PKU, breast cancer, obesity, autism, and cardiovascular disease. Finally, Wendy goes in depth on the current state and exciting potential of gene therapy while also contemplating the economic implications and ethical nature of gene editing.
We discuss:
Wendy's interest in genetics and work as a physician-scientist [2:45];
The genetics of phenylketonuria (PKU), a rare inherited disorder [5:15];
The evolution of genetic research: from DNA structure to whole genome sequencing [18:30];
Insights and surprises that came out of the Human Genome Project [28:30];
Overview of various types of genetic tests: direct-to-consumer, clinical, whole genome sequencing, and more [34:00];
Whole genome sequencing [39:30];
Germline mutations and the implications for older parents [45:15];
Whole exome sequencing and the importance of read depth [50:30];
Genetic testing for breast cancer [54:00];
What information does direct-to-consumer testing provide (from companies like 23andMe and Ancestry.com)? [1:01:30];
The GUARDIAN study and newborn genetic screening [1:06:30];
Treating genetic disease with gene therapy [1:18:00];
How gene therapy works, and the tragic story of Jesse Gelsinger [1:22:00];
Use cases for gene therapy, gene addition vs. gene editing, CRISPR, and more [1:28:00];
Two distinct gene editing strategies for addressing Tay-Sachs and fragile X syndrome [1:37:00];
Exploring obesity as a polygenic disease: heritability, epigenetics, and more [1:41:15];
The genetics of autism [1:48:45];
The genetics of cardiovascular disease [2:01:45];
The financial costs and economic considerations of gene therapy [2:06:15];
Keith Flaherty is the director of clinical research at the Massachusetts General Hospital Cancer Center and a previous guest on The Drive. In this episode, Keith first delves into the statistics on cancer's prevalence as we age, underscoring the significance of finding effective treatments and early detection methodologies. He touches on the history of cancer therapeutics and illuminates the notable enhancements in cancer therapy within the last decade that are setting the stage for a promising future. He goes into detail on the potential of immunotherapy and therapies that can combat cancer's evasive tactics while explaining some of the existing challenges around specificity, cost, and scalability. Additionally, Keith highlights the significant leap in early detection methodologies, namely liquid biopsies, which have the potential not only to determine if a cancer is present in an early stage, but also identify the possible tissue of origin.
We discuss:
Keith's interest and expertise in cancer [3:15];
Cancer deaths by decade of life, and how cancer compares to other top causes of death [7:00];
The relationship between hormones and cancer [12:00];
The link between obesity and cancer [18:45];
Current state of treatments for metastatic cancer and reasons for the lack of progress over the decades [22:30];
The interplay between the immune system and cancer cells [32:00];
Different ways cancer can suppress the immune response, and how immunotherapy can combat cancer's evasive tactics [39:30];
Elimination of a substantial portion of cancers through immune cell engineering faces challenges of specificity, cost, and scalability [52:15];
Why TIL therapy isn't always effective, and the necessity for multimodal therapy to address various aspects of the cancer microenvironment [1:01:00];
Potential developments in cancer therapy over the next five years: T-cell activation, metabolic interventions, targeting tumor microenvironments, and more [1:06:30];
The challenge of treating metastatic cancer underscores the importance of early detection to improve survivability [1:19:15];
Liquid biopsies for early detection of cancer and determining the possible tissue of origin [1:24:45];
Commercially available cancer screening tests [1:33:45];
How to address the disparity in cancer care, and the exciting pace of progress for cancer detection and treatment [1:40:15]; and
In this "Ask Me Anything" (AMA) episode, Peter delves into the realm of genetics, unraveling its connection to disease and emphasizing the value of understanding one's genetic risks. He elucidates essential background knowledge on genetics before delving into the myriad reasons why individuals might consider genetic testing. Peter differentiates scenarios where genetic testing provides genuine insights from those where it may not be as useful. From there, Peter explores a comprehensive comparison of commercial direct-to-consumer genetic tests, providing insights on interpreting results and identifying the standout options for gaining insights into personal health.
If you're not a subscriber and are listening on a podcast player, you'll only be able to hear a preview of the AMA. If you're a subscriber, you can now listen to this full episode on your private RSS feed or our website at the AMA #50 show notes page. If you are not a subscriber, you can learn more about the subscriber benefits here.
We discuss:
Defining the term "genetics" and why it's important [2:15];
What is DNA, and how does it impact our biology and traits? [5:45];
How are genetics passed down from parent to child? [8:45];
How much do genes vary across individuals? [13:00];
Which traits are determined by genetics versus experience or environmental factors? [17:00];
Reasons for genetic testing [22:30];
What exactly is being measured by a genetic test? [29:15];
Testing for monogenic disorders [35:15];
Understanding polygenic risk [39:30];
Is genetic testing more important for someone who doesn't know their family history? [40:45];
What does it mean to be positive for a particular variant? [43:00];
What does it mean to be negative for a particular variant? [45:45];
How does someone get genetic testing through their healthcare provider, and how are these tests performed? [48:15];
The financial cost of various genetic tests [54:30];
Could having a risk allele for a disease result in an increase in one's insurance premium? [57:15];
Other risks associated with genetic testing [59:00];
How do commercial, direct-to-consumer genetic tests compare to the information one might receive from clinical genetic testing? [1:01:45];
Are certain direct-to-consumer tests better than others? [1:03:45];
How long until whole genome sequencing becomes genuinely useful? [1:16:00];
How useful are personalized dietary recommendations based on genetics? [1:18:15];
Final thoughts and advice regarding genetic testing [1:20:00]; and
Oliver Burkeman is the author of The New York Times best-seller Four Thousand Weeks: Time Management for Mortals. In this episode, Oliver delves into the pervasive idea that time can be mastered, exploring whether maximizing productivity is an attainable goal or a perpetual trap. He discusses the allure of attempting to control time—and, therefore, the future—and shares his personal journey of experimenting with diverse time management techniques that failed to deliver the emotional satisfaction he sought. Ultimately, they explore the mismatch between being a finite human and existing in a world of infinite possibilities and how all of these concepts intertwine with finding a sense of purpose and meaning. Additionally, Oliver shares insights from his book on productivity, using our time wisely, and embracing our finitude to live a more fulfilling life.
We discuss:
Oliver's experience that led him to write the book Four Thousand Weeks [3:15];
Human's relationship with time and the struggle with the finite nature of time [7:15];
How productivity can be a trap [11:00];
The fallacy that being more efficient will open up more time and bring a feeling of control [16:45];
The paradoxical nature of trying too hard to be present in the current moment [22:45];
The value of relationships in meaningful experiences and fulfillment, and how time gets its value from being shared [26:45];
The importance of time synchronicity [36:00];
Identifying your biggest priorities and the paradox of wanting to do more than you have time for [41:00];
Oliver's moment of clarity in 2014 [47:15];
The role of a sense of purpose in fulfillment [50:15];
Reconciling the finite nature of time and letting go of trying to master your time [59:00];
Why we tend to have a future-focused attitude and how to combat that with atelic activities [1:05:45];
The power of shifting your perspective about time and your experiences [1:12:45];
How to operationalize the three principles for the dilemma of finite time [1:20:15];
Harnessing the power of patience in the face of a problem or experience [1:28:00];
The value of incrementalism for being productive [1:34:15];
Embracing your finitude with curiosity [1:38:00];
Acting on an idea in the moment rather than letting the idea be the obstacle [1:41:15]; and
Adam Cohen is an orthopedic surgeon with expertise in sports medicine. In this episode, Adam breaks down the anatomy of the lower extremities: the hip, knee, ankle, and foot. He explains in detail the common injuries, sources of pain, and what leads to the development of arthritis. He lays out the non-surgical and surgical treatment options as well as the factors that determine whether surgery is appropriate. The discussion includes various procedures like hip replacement, knee replacement, ACL reconstruction, repair of meniscus tears, and more. Additionally, Adam sheds light on the utility of biological therapies like stem cells and platelet-rich plasma (PRP) and how they compare to more traditional approaches.
We discuss:
Anatomy of the hip, hip dysplasia in infants, and the development of arthritis [3:00];
Diagnosing hip pain in people under 50, stress fractures in the femoral neck, and more [11:15];
Common hip injuries, gender differences, and problems that occur when the hip isn't formed normally [19:30];
Advancements in hip replacement surgery [25:15];
Common hip problems in people over age 60 [27:30];
The importance of muscular strength around the hips for injury prevention [30:30];
Hip fractures due to osteopenia and osteoporosis [36:00];
The utility of biological therapies like stem cells and platelet-rich plasma (PRP) [40:30];
Cortisone as a treatment to delay the need for surgical intervention [53:30];
Anatomy of the knee [56:30];
Are activities like running that amplify forces bad for the knee? [59:45];
Risk of future knee issues and arthritis following an ACL tear or other substantial knee injury [1:04:30];
How the ACL injury happens and how it is repaired [1:08:30];
Arthritis of the knee [1:19:00];
Meniscus tears: how they happen and when surgery is appropriate [1:21:30];
Total knee replacement: when it's appropriate and how the recovery process compares to hip replacement [1:30:30];
Learning from elite athletes, heart rate recovery, V02 max, and other metrics [1:58:45];
Surgical vs. non-surgical approaches to various knee injuries [1:40:45];
Achilles tendon: tendinitis, rupture of the Achilles tendon, and prevention strategies [1:44:15];
Anatomy of the ankle and foot [1:49:00];
Common injuries to the ankle and foot [1:51:15];
Tips for finding a good orthopedic surgeon [2:01:45]; and
Stuart McGill is a distinguished professor emeritus at the University of Waterloo and the chief scientific officer at Backfitpro where he specializes in evaluating complex cases of lower back pain from across the globe. In this episode, Stuart engages in a deep exploration of lower back pain, starting with the anatomy of the lower back, the workings of the spine, the pathophysiology of back pain, and areas of vulnerability. He challenges the concept of nonspecific back pain, emphasizing the importance of finding a causal relationship between injury and pain. Stuart highlights compelling case studies of the successful treatment of complex cases of lower back pain, reinforcing his conviction that nobody needs to suffer endlessly. He also covers the importance of strength and stability, shares his favorite exercises to prescribe to patients, and provides invaluable advice for maintaining a healthy spine.
We discuss:
Peter's experience with debilitating back pain [3:00];
Anatomy of the back: spine, discs, facet joints, and common pain points [14:15];
Lower back injuries and pain: acute vs. chronic, impact of disc damage, microfractures, and more [24:30];
Why the majority of back injuries happen around the L4, L5, and S1 joints [30:45];
How the spine responds to forces like bending and loading, and how it adapts to different athletic activities [36:00];
The pathology of bulging discs [43:00];
The pathophysiology of Peter's back pain, injuries from excessive loading, immune response to back injuries, muscle relaxers, and more [45:45];
The three most important exercises Stuart prescribes, how he assesses patients, and the importance of tailored exercises based on individual needs and body types [56:00];
The significance of strength and stability in preventing injuries and preserving longevity [1:08:00];
Stuart's take on squats and deadlifting: potential risks, alternatives, and importance of correct movement patterns [1:19:15];
Helping patients with psychological trauma from lower back pain by empowering them with the understanding of the mechanical aspects of their pain [1:29:45];
Empowering patients through education and understanding of their pain through Stuart's clinic and work through BackFitPro [1:38:30];
When surgical interventions may be appropriate, and "virtual surgery" as an alternative [1:46:30];
Weakness, nerve pain, and stenosis: treatments, surgical considerations, and more [1:55:15];
Tarlov cysts: treatment and surgical considerations [2:00:00];
The evolution of patient assessments and the limitations of MRI [2:02:00];
Pain relief related to stiffness and muscle bulk through training [2:06:45];
Advice for the young person on how to keep a healthy spine [2:14:00];
Resources for individuals dealing with lower back pain [2:25:15]; and
Michael "Micky" Collins is an internationally renowned expert in sports-related concussions and a consultant for multiple professional sports organizations. In this episode, Mickey first explains the definition and diagnosis of a concussion, as well as the diverse signs and symptoms associated with different types of concussions. He discusses the risk factors that contribute to increased susceptibility and/or severity of concussions in certain individuals, emphasizes the significance of prompt treatment, and uses case studies to illustrate the latest in treatment protocols and recovery process. Additionally, Mickey provides insight into the evolving field of concussion treatments, including the exploration of hyperbaric oxygen and synthetic ketones. He gives advice to parents of kids who play sports and discusses the promising prospects in the realm of concussion management.
We discuss:
Micky's interest in concussion and how he started the first concussion clinic [3:15];
Concussion: definition, pathophysiology, and risk factors making someone more susceptible [9:45];
Symptoms of concussion, predictors of severity, and the importance of early and effective treatment [20:00];
The six types of concussion, the effectiveness of treatment, and factors that impact recovery [25:45];
The importance of seeing a specialist and the prognosis for recovery [30:00];
Case study of a racecar driver who suffered a vestibular concussion [32:15];
Why vestibular concussions are particularly problematic [42:45];
A treatment plan for the racecar driver, possible use of medications, and how to address the root cause [45:45];
Exploring alternative treatments: hyperbaric oxygen, synthetic ketones, and more [52:00];
The natural history of a concussion if untreated and the effect, if any, of concussion on subsequent risk of brain disease [57:15];
Chronic traumatic encephalopathy (CTE) [1:01:45];
Advice for parents of kids who play sports: when and where to seek treatment for a possible concussion [1:04:45];
Is there any evidence that the APOE4 genotype increases susceptibility to concussion or TBI? [1:10:15];
The increased risk of concussions in older adults and a case study of a 90-year-old patient who suffered a head injury in a fall [1:11:15];
Funding for concussion research and fellowship programs to train concussion specialists [1:15:30]; and
In this "Ask Me Anything" (AMA) episode, Peter goes into depth on the topic of brain health, starting with how Alzheimer's disease is diagnosed, the significance of blood-based biomarkers in diagnosis, and what the various APOE gene variants mean in terms of a person's risk of developing Alzheimer's disease. Next, Peter discusses the various strategies for preventing Alzheimer's disease and neurodegeneration. He touches briefly on exercise as a potent tool, but focuses more on lesser-known factors that could impact brain health, such as nutrition supplementation, lipid management, brain games, sauna, oral health, hearing loss, and more.
If you're not a subscriber and are listening on a podcast player, you'll only be able to hear a preview of the AMA. If you're a subscriber, you can now listen to this full episode on your private RSS feed or our website at the AMA #49 show notes page. If you are not a subscriber, you can learn more about the subscriber benefits here.
We discuss:
Topics: exercise, kidneys, and brain health [1:30];
Rucking: advice for beginners, proper load, packs, and shoes [4:30];
Rucking for women, bone health, using a treadmill, zone 2, and more [11:45];
Building vs. maintaining: when and how to transition from the goal of building muscle and strength to focusing on maintenance [16:00];
Should you lift weights before or after a cardio session? [24:00];
Heart rate recovery: defining heart rate recovery and how it relates to cardiovascular fitness [28:45];
How to measure heart rate recovery, and what is considered a "good" heart rate recovery [33:15];
How kidney health and function typically measured [42:30];
Differentiating between creatine and creatinine [48:15];
The cystatin C blood test as a practical way to assess kidney health [52:45];
How kidney function impacts lifespan and the five stages of kidney disease [59:15];
Slowing the decline of kidney function [1:08:15];
The main drivers of kidney disease [1:11:15];
The importance of managing homocysteine levels for brain health [1:14:00];
The relationship between alcohol consumption and brain health [1:21:30]; and
In this special episode filmed live in front of readers of Outlive, Peter answers questions revolving around his concept of the centenarian decathlon. He starts by defining the "marginal decade" and how that shapes his training for the events and activities that make up his personal centenarian decathlon. Peter explains how he coaches patients through the challenges of customizing their own list and building out a training plan, including how to set fitness goals early in life in preparation for the marginal decade. From there, he dives into training within the four pillars (zone 2, VO2 max, stability, and strength), including the minimum effective dose, how to split your time, his personal protocols, and other considerations. Additionally, he touches on bone mineral density, female-specific considerations, working through injuries, and the profound impact training can have on the overall quality of life.
We discuss:
The best interventions for longevity [2:15];
The marginal decade and the centenarian decathlon [4:45];
Peter's personal list of events for his "centenarian decathlon" and how he helps patients create their own list [8:00];
Determining your fitness goals early in life in preparation for the marginal decade, metrics to track, and more [15:00];
How does playing sports like tennis, basketball, or golf fit into training for the centenarian decathlon? [24:15];
Training within the four pillars: minimum effect dose, how to split your time, and other considerations [27:45];
Advice for the older person and why it's never too late to start [33:45];
Bone mineral density and other female-specific concerns and considerations [36:15];
Training advice for those with minimal access to a gym or equipment [39:30];
Injuries: prevention and working through existing conditions [41:00];
Cardiorespiratory training: how to split time between zone 2 and VO2 max training, and different modalities for a true zone 2 workout [44:15];
VO2 max training: modalities, Peter's protocol, and how to monitor progress [54:45];
The profound impact training can have on the overall quality of life [58:15]; and
In this episode, radiologist/engineer, Raj Attariwala, explains how he was able to apply his engineering background to create a unique MRI scanner that is capable of constructing whole-body images with a resolution that is unmatched in the industry. Peter and Raj discuss the implications of such a robust, radiation-free imaging tool on the early detection of cancer. They dive deep into cancer screening and define terms such as sensitivity and specificity that are necessary to really understand this complex space. They then describe the biggest risks involved in this type of screening (false positives) and how Raj's unique technology and process might drive down this risk substantially. But before that, they discuss all the common imaging technology from X-ray, to CT scan, to PET scans, to ultrasound, to MRI, and more. They touch on the history of each, how they work, the usefulness and limitations of each of them, as well as the varying risks involved such as radiation exposure. If you are interested in cancer screening and/or you've ever wondered how any radiology tool works, this episode is for you.
We discuss:
Raj's road from engineering to radiology [2:45];
How X-ray works, the risk of radiation exposure, and the varying amounts of radiation associated with the different imaging technologies [13:00];
Computed tomography scans (CT scans): The history of CT, how it works, and why we use contrast [22:45];
Ultrasound: Benefits and limitations, and a special use for the heart [36:00];
Detecting breast cancer with mammography: When is works, when you need more testing, and defining 'sensitivity' and 'specificity' [46:15];
Magnetic resonance imaging (MRI): How it works, defining terms, and looking at the most common types of MRI [59:00];
Brain aneurysms: Using MRI to find them and save lives [1:18:45];
Raj's unique MRI technology [1:25:15];
The risk of false positives in cancer detection, and how Raj's MRI can reduce the number of false positives (i.e., increase specificity) [1:38:45];
The unique software Raj created to pair with his MRI machine [1:46:15];
Comparing the radiation exposure of a whole-body PET-CT to Raj's equipment (DWIBS-MRI) [1:48:45];
How diffusion-weighted magnetic resonance imaging (DW-MRI) has revolutionized cancer screening [1:50:15];
Why a DW-MRI is still not a perfect test [1:54:15];
The potential for advancing MRI technology: Where does Raj think it could improve in the next 5-10 years? [1:58:00];/li>
Are there any commercially available scanners that can match the resolution of Raj's images? [2:01:00];
Machine learning: When and where might machine learning/AI impact the field of radiology? [2:03:45]; and
Mohit Khera is a world-renowned urologist with expertise in sexual medicine and testosterone therapy. In this episode, Mohit provides a comprehensive overview of male sexual health. He begins with an in-depth exploration of erectile dysfunction, shedding light on its prevalence across different age groups, diagnostic methods, and its intriguing connection to cardiovascular disease. He then ventures into Peyronie's disease, penile fractures, penile enlargement treatments, prolonged erections, premature ejaculation, and anorgasmia. Shifting gears, Mohit delves into the intricate workings of testosterone, DHT, and estrogen, emphasizing their physiological significance and interplay. He explains blood tests for diagnosing low testosterone, the correlation between symptoms and blood levels in cases of low testosterone, and the pros and cons of different methodologies for increasing testosterone. He concludes with a thought-provoking conversation about the role of testosterone in patients with prostate cancer and addresses concerns surrounding DHT, finasteride, and post-finasteride syndrome.
We discuss:
Mohit's career path and interest in sexual medicine and infertility [3:00];
The anatomy of the male genitalia [5:45];
The prevalence of sexual dysfunction, its impact on quality of life, and the importance of seeking help [7:15];
Erectile dysfunction (ED): definition, diagnosis, pathophysiology, and more [11:00];
The history of medications to treat ED and the mechanisms of how they work [15:30];
Relationship between aging and erectile dysfunction and Mohit's approach to treating patients and prescribing medications [20:00];
The impact of lifestyle on sexual health and the association between ED and cardiovascular disease [29:30];
Causes and treatments for Peyronie's Disease, penile fracture, and more [37:30];
The value of ultrasound for ED diagnosis and management strategies [47:45];
Various treatment options for ED: injections, penile prosthesis, and more [50:15];
Priapism (prolonged erection): what is happening and when to seek treatment [57:15];
Shockwave therapy as a treatment for ED [1:02:45];
Stem cell therapy for ED [1:08:15];
Platelet-rich plasma (PRP) injections as a treatment for ED [1:12:00];
Premature ejaculation (PE): prevalence, pathophysiology, and treatment [1:14:45];
Anorgasmia: causes and treatment [1:22:00];
The interplay of sex hormones, the impact of aging, symptoms of low testosterone, and considerations for testosterone replacement therapy (TRT) [1:26:45];
Methods for increasing endogenous testosterone [1:38:45];
Testosterone replacement therapy: various forms of exogenous testosterone, weighing risk vs. reward, and more [1:52:30];
The physiology and purpose of testosterone and DHT, why some men feel fine even with "low" testosterone, personalized approaches to treating low testosterone, and more [2:02:30];
Post-finasteride syndrome [2:09:00];
The role of testosterone in prostate cancer and addressing the notion that TRT could increase risk [2:16:15];
The effects of testosterone as an adjunct to therapy for estrogen-sensitive breast cancer in women [2:27:15];
Resources for those looking for healthcare providers [2:28:45]; and
Sharon Parish is a Professor of Medicine in Clinical Medicine and Clinical Psychiatry at Weill Cornell Medical College and a prominent sexual medicine specialist who has been practicing for 30 years. In this episode, Sharon tackles the topic of women's sexual health, including the conditions associated with decreased sexual function and desire and available treatment options. She explores the influence of sexual health on overall well-being while also examining the potential effects of childbirth, birth control, metabolic health, and more on sexual function and desire. Through case studies, Sharon teases apart the differences between desire and arousal, explains the various factors that affect them, and walks through hypothetical treatment plans for the case study patients. In addition, she delves into the subject of menopause, addressing its impact on sexual health as well as the misguided fears around hormone replacement therapy. Stay tuned for next week's launch of our complementary podcast on men's sexual health.
We discuss:
Sharon's interest in sexual medicine and the current state of the field [3:00];
How hormones change in women over time and how that impacts sexual function [8:15];
Changes after childbirth and its impact on sexual function [11:00];
The role of metabolic health and systemic vascular health in sexual health [20:15];
Conditions associated with decreased sexual function and the importance of sexual health for overall wellbeing [26:15];
Sexual dysfunction case study #1: A 41-year-old mother of two, the sexual response cycle, and the difference between arousal and desire [38:45];
Medications that may reduce sexual desire [49:45];
The effect of birth control pills on sexual desire [56:30];
The importance of testosterone in women for sexual function and desire, and why the FDA hasn't approved exogenous testosterone as a therapeutic [1:01:15];
Challenges faced by physicians who are open to prescribing off-label testosterone for women, and Sharon's approach in managing this aspect with her patients [1:14:30];
A hypothetical treatment plan for the patient in case study #1 [1:26:45];
The role of DHEA (a precursor to testosterone) in female sexual health [1:32:15];
Case study #2: A 30-year-old woman with anorgasmia (inability to orgasm) [1:38:30];
Resources for helping women and their partners to enhance the pleasure experienced during sex, overcome anxiety, and increase desire [1:51:30];
Two drugs for premenopausal women with low desire [1:59:30];
Why treatments are potentially underutilized for both desire and genitourinary syndrome of menopause [2:13:15];
Case study #3: A menopausal woman with symptoms [2:19:00];
Addressing the misguided fears around hormone replacement therapy and cancer [2:24:15];
Symptoms and treatment of genitourinary syndrome of menopause [2:32:45];
Age 65 and beyond, and resources for finding a provider [2:37:30]; and
In this "Ask Me Anything" (AMA) episode, Peter delves into the critical subject of blood pressure, which is one of the three primary causes of atherosclerosis, along with high apoB and smoking. He begins by unraveling the nature of high blood pressure, its prevalence, and why it often goes undiagnosed. Peter describes in detail the proper way to accurately measure blood pressure and what determines a diagnosis. Next, Peter discusses the actionable steps one can take in response to high blood pressure, shedding light on the extent to which factors like weight loss, exercise, and nutrition can make an impact. He also explores the pharmacological options available and offers valuable insights on how to approach them.
If you're not a subscriber and are listening on a podcast player, you'll only be able to hear a preview of the AMA. If you're a subscriber, you can now listen to this full episode on your private RSS feed or our website at the AMA #48 show notes page. If you are not a subscriber, you can learn more about the subscriber benefits here.
We discuss:
Blood pressure and other risk factors for cardiovascular disease [2:30];
Defining blood pressure and the purpose and meaning of a blood pressure measurement [5:45];
The implications of high blood pressure and the importance of maintaining an optimal level [10:30];
The importance of accurate measurements of blood pressure and how Peter approaches the care of patients at the very top range of "normal" [21:45];
The prevalence of high blood pressure—a hidden epidemic? [24:30];
The consequences of high blood pressure on cardiovascular health, brain health, kidneys, and more [27:45];
Low blood pressure: symptoms and consequences [35:30];
How to properly measure blood pressure [37:45];
Daily variance in blood pressure and the transient changes in blood pressure during exercise [48:00];
Primary hypertension vs. secondary hypertension: what to look for [51:45];
Tommy Wood is an Assistant Professor of Pediatrics at the University of Washington, where he studies brain injury and how lifestyle choices and environmental factors contribute to brain health, cognitive function, and chronic disease. In this episode, Tommy delves into the complexities of age-related cognitive decline and explores interventions to counteract it. Drawing from his experience working with Formula 1 drivers, he highlights the connection between cognitive function and the right type of demands and training leading to improvement. Next, he explores the various theories on the different types of pathology in dementia and neurodegeneration. He makes the case that a large fraction of dementia is preventable through lifestyle choices and nutrient status, and provides an in-depth overview of interventions and supplements that support cognitive function. Finally, he provides a comprehensive overview of head injuries, including concussions and traumatic brain injuries (TBIs), discussing symptoms, how to mitigate damage following an incident, and long-term management.
We discuss:
Tommy's professional work, unique skill sets, and interests [3:00];
Age-related decline in cognitive function and memory [5:45];
Improving brain function with the right level and type of demand [20:15];
Formula 1 as a model for how to perform under high cognitive demand and how to increase multitasking capacity [31:30];
Advice for the person reaching middle life looking to mitigate cognitive decline [37:45];
Tasks and activities that support and improve cognitive function [45:30];
Neuropathology of Alzheimer's disease: exploring the role of amyloid and tau proteins [49:30];
Why Tommy believes dementia research funding should be focused on environmental and lifestyle-based risk factors [1:05:15];
Benefits of lowering homocysteine and boosting omega-3's, and evidence-based supplements that support cognitive function [1:09:00];
A unifying theory of dementia [1:20:45];
How muscular strength can help with both the prevention and survivability of dementia [1:24:15];
Head injuries: comparing concussions against traumatic brain injuries (TBIs), mitigating the damage after an incident, and the long-term management of head injuries [1:29:15];
Is hyperbaric oxygen treatment helpful after a TBI? [1:45:45];
Supplements that aid recovery from a TBI: creatine, DHA, and choline [1:49:30];
Demands faced by F1 drivers, and testing interventions to improve their performance [1:57:30]; and
In this special episode of The Drive, Peter provides a comprehensive overview of the various endocrine systems: the thyroid system, the adrenal system, and the sex hormone system (for both men and women). He walks through the basic biology and the feedback cycles that regulate the production of these hormones and discusses the various options for the treatment of hormone deficiencies. In addition, Peter delves into hormone replacement therapy (HRT), providing nuanced insights into its appropriate usage and the clinical approach he adopts when working with patients.
Peter supplements these explanations with whiteboard illustrations. For a more complete understanding, we highly recommend watching these videos over just listening. The videos can be found on our YouTube channel or on the show notes page.
John Kastelein is a renowned expert in lipoprotein metabolism and atherosclerotic cardiovascular disease (ASCVD) research. In this discussion, John delves deep into familial hypercholesterolemia (FH), a genetic disorder characterized by high levels of LDL cholesterol in the blood that increases the risk of developing heart disease. He covers its definition, genetic underpinnings, and clinical identification. He then explores the therapeutic options available for the prevention and treatment of cardiovascular disease, including the captivating history of CETP inhibitors. He explains the past shortcomings of previous CETP inhibitors before underscoring the compelling potential of the latest iterations, not only for cardiovascular disease but also for conditions like Alzheimer's disease and type 2 diabetes. Moreover, he unveils the intricate role of APOE, shedding light on why the APOE4 isoform codes for a protein that significantly increases the risk of Alzheimer's disease and cardiovascular disease. Concluding the discussion, John shares a profound sense of optimism, envisioning the possibility of targeted therapeutic interventions for high-risk patients in the near future.
We discuss:
Familial hypercholesterolemia (FH): a genetic condition [4:30];
Differentiating between phenotype and genotype when it comes to FH [9:45];
The pathophysiology related to mutations of FH [15:30];
Clinical presentations, physical manifestations, and diagnosis of FH [22:00];
Why a small fraction of people with FH do not develop premature ASCVD [34:15];
Treatment and prevention for those with FH [39:45];
Addressing the assertion by some that elevated LDL is not casual in cardiovascular disease [52:45];
The history of CETP inhibitors, and the role of the CETP protein [55:45];
The thrifty gene hypothesis and why genes underlying FH may have been preserved [1:09:00];
The compelling potential of the latest CETP inhibitor (obicetrapib) [1:13:00];
Promising results from phase 3 trials exploring obicetrapib [1:27:45];
Why the APOE4 allele increases the risk of Alzheimer's disease, and the connection to blood lipids [1:41:30];
The role of APOE in cardiovascular disease [1:51:45];
In this "Ask Me Anything" (AMA) episode, Peter delves deep into the data surrounding different forms of cold therapy, including cold water immersion, cryotherapy, and cold showers, aiming to unveil the potential benefits and drawbacks associated with cold therapy. He dissects the studies examining the effects of cold therapy on delayed onset muscle soreness (DOMS), activation of brown adipose tissue, and its potential impact on mood and as a therapeutic approach for depression. Furthermore, Peter discusses the potential negative impact cold therapy may have on muscular hypertrophy and offers his perspective on the extent to which the data support the notion of cold therapy providing longevity benefits. Finally, he also discusses the existing consensus, or lack thereof, regarding the optimal structure of an effective cold therapy protocol.
If you're not a subscriber and are listening on a podcast player, you'll only be able to hear a preview of the AMA. If you're a subscriber, you can now listen to this full episode on your private RSS feed or our website at the AMA #47 show notes page. If you are not a subscriber, you can learn more about the subscriber benefits here.
We discuss:
Overview of discussion on cold therapy (and a Formula 1 tangent) [1:45];
The most common cold exposure therapies [5:45];
Potential benefits of cold water immersion: a look at the data [9:30];
Comparing the effects of cold water immersion with whole-body cryotherapy [18:30];
The potential impact of cold exposure on mood and as a treatment for depression [20:45];
How do cold showers compare to cold water immersion? [28:15];
Cold exposure and the activation of brown adipose tissue (BAT) [34:15];
Things that clearly impact brain health: smoking, alcohol, sleep, head injuries, blood pressure, and more [34:15];
Exercising in cold temperatures: impact on exercise performance [38:30];
Potential downsides of cold therapy and its impact on hypertrophy, strength, and recovery [44:45];
Are the blunting effects of cold on hypertrophy due to the effects on inflammation? [50:45];
Does cold exposure offer any potential geroprotective benefits? [53:15];
Cold therapy protocols for delayed onset muscle soreness (DOMS) [56:30];
Summarizing the data and takeaways from Peter [1:01:00]; and
#253 ‒ Hormone replacement therapy and the Women's Health Initiative: re-examining the results, the link to breast cancer, and weighing the risk vs reward of HRT | JoAnn Manson, M.D.
JoAnn Manson is a world-renowned endocrinologist, epidemiologist, and Principal Investigator for the Women's Health Initiative (WHI). In this episode, she dives deep into the WHI to explain the study design, primary outcome, confounding factors, and nuanced benefits and risks of hormone replacement therapy (HRT). JoAnn reflects on how a misinterpretation of the results, combined with sensationalized headlines regarding an elevated risk of breast cancer, led to a significant shift in the perception and utilization of HRT. From there, they take a closer look at the breast cancer data to separate fact from fiction. Additionally, JoAnn gives her take on how one should weigh the risks and benefits of HRT and concludes with a discussion on how physicians can move towards better HRT practices.
We discuss:
The Women's Health Initiative: the original goal of the study, hormone formulations used, and potential confounders [4:15];
Study design of the Women's Health Initiative, primary outcome, and more [16:00];
JoAnn's personal hypothesis about the ability of hormone replacement therapy to reduce heart disease risk prior to the WHI [26:45];
The relationship between estrogen and breast cancer [30:45];
Why the WHI study was stopped early, and the dramatic change in the perception and use of HRT due to the alleged increase in breast cancer risk [37:30];
What Peter finds most troubling about the mainstream view of HRT and a more nuanced look at the benefits and risks of HRT [45:15];
HRT and bone health [56:00];
The importance of timing when it comes to HRT, the best use cases, and advice on finding a clinician [59:30];
A discussion on the potential impact of HRT on mortality and a thought experiment on a long-duration use of HRT [1:03:15];
Moving toward better HRT practices, and the need for more studies [1:10:00]; and
Rhonda Patrick, Ph.D., is a scientist with expertise in the areas of aging, cancer, and nutrition who translates complex scientific topics into actionable insights on her podcast, Found My Fitness. In this episode, Rhonda provides her latest thinking as it relates to Alzheimer's disease including the possibility of a vascular hypothesis as well as the factors that can impact disease risk such as type 2 diabetes, blood pressure, omega supplementation, exercise, sauna, and more. She also touches on cancer risk including the relationship between cancer and exercise as well as the link between alcohol consumption and cancer. Additionally, Rhonda explains her new focus on exercise and protein consumption as well as how her perspective has shifted as it pertains to fasting and time-restricted feeding.
We discuss:
Alzheimer's disease: Rhonda's evolved thinking on neurodegenerative diseases [2:30];
The breakdown of the blood-brain barrier in neurodegenerative disease [8:45];
An explanation for the observation that type 2 diabetes increases risk of Alzheimer's disease [15:45];
The role of omega-3 fatty acids (EPA and DHA) in brain health and prevention of neurodegeneration [19:45];
Comparing the preventable nature of type 2 diabetes, atherosclerosis, cancer, and dementia [32:15];
Blood pressure: an important modifiable lifestyle factor that can affect Alzheimer's disease risk [35:15];
Rhonda's outlook on "precision medicine" as it pertains to one's genetic predispositions [38:45];
Possible mechanisms by which exercise reduces the risk of Alzheimer's disease [45:45];
Building your aerobic pyramid: neurobiological effects of exercise, benefits of lactate peaks, and more [53:45];
Maximizing mitochondrial biogenesis: alternative training approaches and strategies [58:45];
Possible brain benefits of sauna, and Rhonda's personal protocol [1:09:30];
The relationship between cardiorespiratory fitness and dementia risk [1:15:30];
How exercise may reduce the risk of cancer [1:20:30];
The overarching impact of exercise on health, and the importance of focusing the factors that matter most [1:33:15];
Impact of alcohol consumption on breast cancer risk and overall health [1:37:15];
Exercise as an intervention for poor sleep habits [1:42:30];
The longevity benefits of consuming adequate protein and strength training to preserve muscle mass and strength [1:46:30];
How to get enough of the right kind of protein in your diet [2:05:15];
Fasting: weighing the risk vs. reward [2:12:15];
How Rhonda's views have shifted on diet and exercise [2:15:30];
How to follow Rhonda's work and more about the benefits of lactate for the brain [2:21:00]; and
In this episode, Robert Sapolsky, Ph.D., discusses the widespread impact of stress on our physical and emotional health as well as the mechanisms by which it can precipitate chronic illness, dementia, depression, and more. He also provides insight into the factors that contribute to the stress response (and our ability to handle it) such as social rank, personality, environment, and genetics. Lastly, we discuss how our behavior is altered in the face of stress and how that not only has a pervasive effect on a personal level, but also on society as a whole in how we interact with each other.
We discuss:
Background, interest in stress, and Robert's time in Kenya studying baboons [2:45];
Physiology of a stress response, and why it's ingrained in our DNA [9:45];
Individual variation in the response to stress, and how everyone has a different optimal level [19:45];
How social rank and personality differences affect our stress response [26:30];
What's happening in the brain when faced with stressful situations? [35:00];
What makes the human brain different than all other species? [44:15];
Imprinting stress to your kids epigenetically [48:00];
The role of stress on memory and the consequences of hypercortisolemia [53:00];
The impact of subjective socioeconomic status and social media on stress levels and health [57:45];
Tips for managing stress in the modern world [1:13:15];
What Robert learned about himself studying the social behavior of baboons [1:25:30];
The multilayered factors behind every human behavior, the context of "good and bad", and exploring the human capacity of the wild extremes of violence and altruism from moment to moment [1:30:15];
PMS: How two women with identical hormone levels can have completely different emotional experiences [1:34:45];
How much of a role do genes play in depression and other emotional states? [1:38:00];
Why is cortisol elevated under sleep deprivation? [1:46:00];
The impact of stress on cancer [1:50:30];
The impact of stress on atherosclerosis, dementia, addiction, and depression [1:57:00];
Impulsiveness, impaired judgment, and lack of empathy in times of stress [2:01:45];
What advice would Robert give his 25-year-old self? [2:08:45]; and
In this "Ask Me Anything" (AMA) episode, Peter goes into depth on the topic of brain health, starting with how Alzheimer's disease is diagnosed, the significance of blood-based biomarkers in diagnosis, and what the various APOE gene variants mean in terms of a person's risk of developing Alzheimer's disease. Next, Peter discusses the various strategies for preventing Alzheimer's disease and neurodegeneration. He touches briefly on exercise as a potent tool, but focuses more on lesser-known factors that could impact brain health, such as nutrition supplementation, lipid management, brain games, sauna, oral health, hearing loss, and more.
If you're not a subscriber and are listening on a podcast player, you'll only be able to hear a preview of the AMA. If you're a subscriber, you can now listen to this full episode on your private RSS feed or our website at the AMA #46 show notes page. If you are not a subscriber, you can learn more about the subscriber benefits here.
We discuss:
Diagnosing Alzheimer's disease [2:45];
Biomarkers for Alzheimer's disease, the C2N test, and other tools for diagnosis [7:30];
Genetic component of Alzheimer's disease: genes that confer risk [12:45];
Understanding your APOE status and why it's important to know [17:15];
The prevalence of Alzheimer's disease and other forms of dementia, and who is at higher risk [21:15];
Can the risk of Alzheimer's disease be decreased with behavioral changes? [24:15];
Overview of modifiable behaviors that potentially play a role in risk reduction of neurodegeneration [30:15];
Things that clearly impact brain health: smoking, alcohol, sleep, head injuries, blood pressure, and more [34:15];
How nutrition impacts brain health: common diets, metabolic health, energy balance, and more [46:15];
Comparing common diets: data showing the association between the incidence of Alzheimer's disease and specific diets [59:45];
Supplements: EPA and DHA, vitamin D, and B vitamins [1:13:00];
Supplements: theracurmin, cocoa flavonols, and magnesium L-threonate [1:25:15];
Impact of exercise on brain health, minimum effective dose, and the most important types of exercise [1:33:00];
Challenging the mind with brain games—does it impact neurodegeneration? [1:43:00];
The data on sauna and brain health [1:49:45];
Oral health and its association with brain health [1:52:45];
How reducing lipids can improve brain health and prevent neurodegeneration [1:55:30];
The potential impact of hearing loss on brain health and neurodegeneration [2:04:30]; and
Andy Galpin is a Professor of Kinesiology at California State University at Fullerton, where he studies muscle adaptation and applies his research to work with professional athletes. In this episode, Andy returns to the podcast and continues the conversation about training for longevity. He examines the training practices of powerlifters, Olympic weightlifters, Strongmen/women, CrossFit athletes, and sprinters in order to extract insights that can be applied to the individual wanting to optimize for longevity. Andy goes into detail about exercise load and repetition, training volume, the importance of learning proper movement patterns, the advantage of working to technical failure instead of the number of reps, and much more. Andy ties the discussion together by providing a hypothetical training plan for an individual wanting to optimize for longevity and offers advice for avoiding injury.
We discuss:
Review of the function and organization of skeletal muscle [3:15];
Review of muscle fiber types [9:30];
Hypertrophy: changes in muscle fibers and the underlying mechanisms that make a muscle grow [19:30];
Defining sarcoplasmic hypertrophy and how it relates to the number of reps in a set [30:15];
Training for maximum strength: what we can learn from powerlifters and a hypothetical training plan [32:45];
Ideal reps, volume, and load for the powerlifter [44:45];
What should powerlifters do on their off days? [56:45];
Are there consequences of powerlifting on long-term health? [1:02:00];
Defining Olympic weightlifting: a test of power [1:04:30];
Training principles of Olympic weightlifting [1:07:45];
Tracking power output when training [1:17:15];
Frequency of training for Olympic weightlifting [1:22:15];
How post-activation potentiation (and the opposite) can improve power training and speed training [1:24:30];
The Strongman competition: more breadth of movement, strength, and stamina [1:32:00];
Training principles of Strongmen and advice for someone new to the Strongman competition [1:36:45];
CrossFit: a combination of weightlifting movements, endurance, and circuit training [1:50:15];
Learning from elite athletes, heart rate recovery, V02 max, and other metrics [1:58:45];
Optimizing towards being a well-rounded athlete as opposed to a specialist [2:09:45];
What we can learn from the sprinters about speed, acceleration, peak velocity, and technique [2:17:45];
A training plan for the "centenarian athlete" [2:24:30];
Debunking some training and exercise myths [2:33:00];
The "do nots" of training and tips for avoiding injury [2:34:15]; and
Andrew Huberman is a Professor of Neurobiology at Stanford University and host of the Huberman Lab podcast. In this episode, Andrew begins with a fascinating discussion about the brain, including the role of the prefrontal cortex in adjusting your ruleset to match your setting, the neural circuitry underlying the ability of stress to limit creativity and problem-solving, the effect of belief on physiology and performance, and more. He speaks about vision being our "superpower" and compares this to animals that rely more on other senses. Next, he opens up about his personal journey, the struggles and losses he has overcome, the value of therapy, and the many great people who helped him along the way. He speaks to his love of biology and discovery and the importance of staying true to your passion rather than being driven purely by ambition. Lastly, the conversation includes a look to the future of Andrew's scientific work and podcast as well as his unique approach to communicating science and tackling the issue of scientific illiteracy.
We discuss:
Exercise under blood flow restriction, lactate utilization, and transient changes in the brain function in response to adrenaline and stress [3:30];
The role of the prefrontal cortex in governing rulesets [9:15];
New discoveries about the circuitry between the prefrontal cortex, insula, and amygdala, and the insights gleaned about brain function in different emotional states [15:30];
Comparing human vision and other senses to animals [26:00];
A deep dive into vision: evolutionary adaptations, facial recognition, color, and more [39:45];
Sense of smell, pheromones, and why evolution developed better vision over smell [46:30];
The relationship between visual input and time perception [55:30];
Mindset effects: the effect of belief on physiology and performance [1:00:45];
Accessing higher levels of creativity with broadening rulesets and the limiting nature of stress and fear on creativity [1:05:30];
Stress and fear increase autonomic arousal, limit access to rulesets, and inhibit performance [1:12:15];
Andrew's upbringing, early childhood, and tough adolescent years [1:15:00];
Andrew's time in a residential treatment program and how he benefited from therapy [1:20:15];
The beginning of positive changes in Andrew's young life [1:28:30];
Andrew's decision to turn his life around [1:37:00];
A new passion for science and exercise helps Andrew [1:42:00];
The difference between a postdoc and a PhD [1:54:15];
Staying in touch with the love of biology and not getting pulled into ambition [1:59:15];
Andrew starts his own lab, and continues work to overcome his demons [2:07:00];
The loss of three mentors leads to deep soul searching [2:12:00];
What motivated Andrew to begin his podcast [2:18:00];
Looking to the future of Andrew's scientific work, podcast, and more [2:22:45];
Andrew's unique approach to communicating science and the issue of scientific illiteracy [2:30:00]; and
After more than six years of research, planning, and writing, Peter's book, Outlive: The Science and Art of Longevity, is officially available as of March 28th. In this episode, Peter sits down with co-author Bill Gifford to provide a behind-the-scenes look into the writing process, including the motivation for making it happen, how the book evolved over the course of the writing process, and why certain topics were chosen (and omitted). Additionally, they discuss how the book is structured and touch on a few of the book's main themes to give potential readers an idea of what they can expect.
We discuss:
The meaning of the book's title and subtitle [3:00];
Finding the right art for the book cover [9:00];
Who is Bill Gifford, and how did he get involved in the book? [16:15];
How Peter's writing evolved over the six years it took to write this book [25:00];
The structure of the book and what people can expect to learn [29:00];
How the writing of the book and the podcast interviews have shaped Peter's thinking and approach to translating science [32:45];
Making the book stand the test of time despite the constant evolution of science and medicine [36:00];
Objective, strategy, and tactics [39:30];
Exciting possible progressions in science and medicine over the next decade [42:15];
What is holding back "medicine 3.0" from being the norm? [46:00];
How the book compares to the podcast in terms of technicality and readability for the layman [49:00];
Motivation to write the book and insights into challenges around the writing process [57:15];
Peter's decision to be the reader for the audiobook [1:10:30];
The many painstaking last-minute changes and edits that brought the book together and made it better [1:19:00];
Peter and Bill's favorite parts of the book [1:27:30];
The incredible team of people supporting the book [1:31:30]; and
Ethan Weiss is a preventative cardiologist at UCSF, an entrepreneur-in-residence at Third Rock Ventures, where he is working on a project related to cardiometabolic disease, and a previous guest on The Drive. In this episode, Ethan compares and contrasts the diagnostic imaging tools, CAC (coronary artery calcium score) and CTA (CT angiography), used to image plaque—including the latest in CTA software—and how these tools inform our understanding of ASCVD risk and guide clinical decision-making. Ethan discusses the types of plaque that cause events and the data that make a case for optimal medical therapy over stenting outside of particular cases. He explains why high blood pressure is problematic and walks through the data from clinical trials testing aggressive treatment. He talks about the best way to actually measure blood pressure, why we shouldn't simply accept that blood pressure rises with age, and how he uses different pharmaceutical agents to treat hypertension. Additionally, Ethan explains our current, but limited, understanding of the role of metabolic health in ASCVD. He discusses the impact of fat storage capacity and the location of fat storage and explains how and why there is still a residual risk, even in people who have seemingly normal lipids, don't smoke, and have normal blood pressure.
We discuss:
Ethan's entrepreneurial work in the cardiometabolic disease space [4:30];
Calcium scans (CAC scores) and CT angiography (CTA), and how it informs us about ASCVD risk [6:00];
Peter's historical CAC scores, CTA results, and how one can be misled [10:45];
How Peter's CTA results prompted him to lower his apoB [14:45];
Calcium scans vs. CT angiogram (CTA) [21:15];
How Ethan makes clinical decisions based on CTA results and plaque burden, and the importance of starting treatment early to prevent ASCVD [28:15];
Improved methods of CTA to grade plaque lesions and how it's shaped medical decisions such as stenting [33:45];
Why Ethan favors optimal medical therapy over stenting outside of particular situations [41:45];
The need for FFR CTA, and the potential for medical therapy to eliminate ASCVD [54:00];
The fat attenuation index (FAI) and other ways to measure inflammation in a plaque [57:30];
Statins and exercise may increase the risk of calcification, but what does this mean for risk? [59:45];
The root cause of statin hesitation despite evidence that statins are a profoundly important intervention [1:05:30];
Importance of keeping blood pressure in check, defining what's normal, and whether we should just accept higher blood pressure with age [1:10:45];
Blood pressure variability, how to best measure it, and data suggesting the enormous impact of keeping blood pressure down [1:21:00];
Drugs for treating high blood pressure recommended by the ALLHAT trial [1:35:15];
What the SPRINT trial says about the aggressive treatment of hypertension, and the risks of such treatment [1:38:15];
Confirmatory results in the STEP trial for blood pressure, and how Ethan uses the various pharmacological agents to lower blood pressure in patients [1:43:15];
The role metabolic health in ASCVD: what we do and don't know [1:51:00];
The impact of fat storage capacity and the location of fat storage on metabolic health and coronary artery disease [1:56:15]; and
In this "Ask Me Anything" (AMA) episode, Peter focuses the discussion on two topics getting a lot of attention recently. He first dives deep into GLP-1 agonists, most notably semaglutide and tirzepatide, which originally came to market as diabetes drugs but are now being studied and prescribed for weight loss. He walks through the data and compares the effectiveness of the two drugs, the side effects, and perhaps more importantly, his reservations around wide use of these drugs and who he would consider to be a candidate for them. Next, Peter discusses how metformin, another drug originally brought to market for diabetes management, gained popularity as a potential longevity drug even for non-diabetics. Peter gives his take on this possibility and reviews data from a more recent study investigating the question of whether metformin should be used for general "geroprotection."
If you're not a subscriber and are listening on a podcast player, you'll only be able to hear a preview of the AMA. If you're a subscriber, you can now listen to this full episode on your private RSS feed or our website at the AMA #45 show notes page. If you are not a subscriber, you can learn more about the subscriber benefits here.
We discuss:
The hype around semaglutide, tirzepatide, and other GLP-1 agonists for weight loss [2:30];
Overview of GLP-1 agonists and why these drugs are getting so much attention [6:15];
Defining the term "geroprotective" [13:30];
Semaglutide: background, brand names, indications, and more [15:15];
Tirzepatide: background, brand names, indications, and more [19:15];
How semaglutide and tirzepatide compare in their efficacy in terms of weight loss and other metabolic health metrics [23:45];
Data showing sustained weight loss and improved metabolic metrics with after more than a year of using semaglutide and tirzepatide [29:00];
What happens to body weight when a patient discontinues the medication? [34:45];
Noteworthy side effects of GLP-1 agonists and similar classes of drugs [40:45];
Increased resting heart rate and other concerning trends in patients using GLP-1 agonists [45:15];
Changes in body composition (body fat and lean muscle) in patients on GLP-1 agonists [50:45];
Possible reasons for the loss of lean muscle mass and tips for protecting lean mass [59:00];
GLP-1 agonists and thyroid cancer [1:01:30];
Who might be a candidate for GLP-1 agonists? [1:03:45];
The large financial cost of this class of drugs [1:08:30];
Metformin as a geroprotective drug: origin of the idea that metformin could be a longevity agent even for non-diabetic patients [1:11:30];
A 2022 study on metformin sheds more light on the question of whether metformin should be used for "geroprotection" in non-diabetics [1:21:00];
Peter's current approach with metformin for his patients [1:25:15]; and
In this "Ask Me Anything" (AMA) episode, Peter explains how to evaluate sugar and its substitutes in the context of health. Peter explores the role of sweeteners in three common use-cases – beverages, protein supplements, and sweet treats – and breaks down how our evolutionary craving for sweetness now clashes with today's food environment. He examines whether sugar is uniquely fattening, the hormonal effects of sugar consumption, and the significance of timing in sugar intake. The episode compares natural versus refined sugars, sugar in beverages versus in solid foods, and the pros and cons of popular sweeteners including saccharin, aspartame, sucralose, allulose, and sugar alcohols like erythritol and xylitol. With a focus on weight management, glycemic impact, gut health, and long-term safety, this episode offers a comprehensive guide to navigating the sweetener landscape with clarity and nuance.
If you're not a subscriber and are listening on a podcast player, you'll only be able to hear a preview of the AMA. If you're a subscriber, you can now listen to this full episode on your private RSS feed or our website at the AMA #74 show notes page. If you are not a subscriber, you can learn more about the subscriber benefits here.
We discuss:
A quick tangent on chess and parenting [2:30];
Overview of key scenarios for evaluating sugar and sweeteners [6:15];
Why humans are hardwired to crave sweetness [13:30];
Evaluating whether sugar is uniquely fattening or more harmful than other macronutrients under isocaloric conditions [15:15];
Why sugar drives appetite: low satiety, insulin response, and reward system activation [18:45];
How sugar type, liquid vs. solid form, and processing level influence appetite and metabolic impact [20:15];
Addressing the common belief that natural sugars are healthier than refined sugars [26:00];
How the timing of sugar consumption alters the body's metabolic response [29:15];
How Peter advises patients on sugar intake, factoring in metabolic health, insulin sensitivity, and activity level [34:45];
The most common sugar substitutes, their sweetness relative to sugar, and their caloric content [36:30];
Evaluating the role of sugar substitutes in weight control: efficacy vs. effectiveness and limitations in study design [40:15];
Assessing the real-world impact of sugar substitutes on weight, and the role of sweetness without calories [44:00];
The impact of sugar substitutes on glycemic control [47:30];
Are microbiome changes from artificial sweeteners substantial enough to cause obesity and diabetes? [50:30];
How Peter advises patients on the use of sugar substitutes across different contexts [52:30];
Allulose—a sweetener with unique satiety and glycemic benefits and potential for weight control [57:15];
Emerging evidence that stevia, monk fruit, and sugar alcohols may provide modest metabolic benefits compared to sugar [1:03:00];
Sugar alcohols explained [1:04:15];
Sugar alcohols and GI issues [1:05:00];
Xylitol's dental health benefits and considerations for use [1:06:30];
Artificial sweeteners and cancer risk: evaluating evidence, the aspartame controversy, and the role of dose in toxicology [1:07:15];
Sugar substitutes and cardiovascular disease: assessing flawed studies and the absence of direct risk evidence [1:11:00];
Why artificial sweeteners seem to attract so many negative headlines [1:12:45];
Balancing benefits and risks of sugar substitutes: guidance for desserts, beverages, and protein products [1:14:15]; and
Lewis Howes is a New York Times best-selling author, entrepreneur, speaker, and host of the popular podcast, The School of Greatness. In this episode, Lewis opens up about the various hardships and traumatic events he experienced starting at a very young age and reveals the valuable lessons he learned as he worked through those traumas to improve his emotional health. He talks about how his past hardships likely contributed to his success in business and athletics, only to leave him feeling unsatisfied and unfulfilled. Next, he discusses how many aspects of his life were suffering, the inflection point that drove Lewis to seek help, and the long but beautiful healing journey that followed. Lewis makes the case that adversity, and even trauma, can be beneficial if one finds meaning in tribulations and has the courage to face one's fears and insecurities. Finally, Lewis shares the many modalities of therapy that helped him along the way and gives advice for those wanting to find inner peace and live a fulfilling, rich, abundant, joyful life.
We discuss:
Lewis's upbringing and the impact of his older brother going to prison [2:45];
Finding lessons in tragedy and adversity [10:45];
Lasting trauma from being sexually abused at age 5 [13:15];
Inflection point that drove Lewis to seek help, and a beautiful experience at a therapeutic workshop [16:45];
A powerful workshop on emotional intelligence jump started Lewis's healing journey [27:30];
How being authentic can strengthen bonds with family and bring inner peace [39:30];
Comparing adversity with trauma and finding meaning in struggle [45:15];
Association between adverse childhood events and diseases in adulthood [56:15];
How addressing his issues with intimate relationships helped Lewis overcome physical pain related to his past trauma [59:15];
Healing is a journey that takes time and requires courage to face your fears and insecurities [1:08:45];
How Lewis thinks about mortality and uses it as motivation to pursue his dreams [1:13:00];
How anyone can benefit from therapy or coaching, and Lewis's advice for finding inner peace [1:22:45];
Lewis's newest book, The Greatness Mindset [1:29:15]; and
Siddhartha Mukherjee is an oncologist, Pulitzer Prize-winning author, and previous guest on The Drive. In this episode, Sid discusses many of the subjects of his latest book, The Song of the Cell, including the incredible discovery of the cell and how it transformed medicine. He explains the evolutionary drive to go from single-cell to multicellular life and unpacks the four different types of cell-based therapies and the problems they are attempting to solve. He also provides the latest in gene therapy, such as CRISPR, and the ethical questions around human gene editing. Additionally, he touches on a number of fascinating topics, such as the challenges of medical science, the human brain, learning styles, his writing process, mental health, and more.
We discuss:
How the cell brings the genome to life, and how Sid's recent book fits into his prior work to tell a story [2:30];
How the germ theory of disease and an understanding of the cell fueled a big leap in medicine [9:45];
What is the evolutionary drive for multicellular life? [17:15];
Four types of cell therapies and the challenges of gene therapy [26:00];
CAR T-cell therapy: promising gene therapy for cancer [36:30];
The possibility of using gene therapy to treat germline mutations like sickle cell disease [41:45];
The incredible revolution of gene editing with CRISPR [45:15];
Ethical questions around human gene editing [52:30];
The complex role of genetics in mental illness [1:01:30];
Two types of problems in science: the "eye in the sandstorm" problem and the "sand in the eye" problem [1:06:15];
Understanding neural networks: an example of the "sand in the eye" problem being solved [1:08:45];
Importance of learning by doing: comparing the learning styles of a doctoral student to a medical student [1:16:30];
Sid's unique and brilliant style of writing [1:20:45];
Falling as the leading cause of accidental death: a liability of multicellular existence [1:25:00];
Sid's struggle with depression and his desire to change the stigma around mental illness [1:29:15]; and
Anthony Hipolito is a sheriff's deputy in Hays County, Texas with over 24 years of experience in law enforcement. In this episode, Anthony discusses his work to spread awareness about illicit fentanyl use and the drastic increase in accidental overdoses, especially in young people. Anthony explains the deadly nature of fentanyl, including how many counterfeit drugs are now being laced with deadly doses of fentanyl. He breaks down how fentanyl is being brought to the US and how younger and younger kids are being targeted. Additionally, Anthony discusses his goal of spreading awareness to our communities and provides important advice for what parents can do.
We discuss:
Anthony's life of service in law enforcement [5:30];
Fentanyl: medical use, recreational use, and the recent rise in prevalence [8:30];
The story of a teenager dying from an accidental overdose of fentanyl [16:30];
The scope of deaths being caused by accidental overdoses (the majority of which are from fentanyl) [23:00];
How young kids are being targeted, and how fentanyl makes it across our borders and gets distributed [28:30];
What happens to a person when they overdose [35:30];
Whether laws around drug possession are helping or hurting, and the need to focus on helping people that feel the need to take these counterfeit drugs [37:00];
How fentanyl is being added to all kinds of drugs that you wouldn't expect [42:45];
What can we do as parents? [47:15];
Narcan: a treatment for opioid overdoses [50:15];
Importance of awareness, having conversations with kids early in life, and other key takeaways for parents [56:30]; and
In this "Ask Me Anything" (AMA) episode, Peter reviews the last 12+ years of his DEXA scan results revealing the changes to his body composition, lean muscle mass, visceral adipose tissue, and more. He explains how his body composition and blood biomarkers were impacted by the various dietary approaches (ketosis, fasting, high protein, etc.) and training protocols (primarily endurance, primarily strength training, etc.) he has undertaken over the years. Furthermore, Peter explains his planned approach moving forward following his most recent DEXA scan in late 2022.
If you're not a subscriber and are listening on a podcast player, you'll only be able to hear a preview of the AMA. If you're a subscriber, you can now listen to this full episode on your private RSS feed or our website at the AMA #44 show notes page. If you are not a subscriber, you can learn more about the subscriber benefits here.
We discuss:
DEXA scans and other methods for tracking body composition [2:30];
Importance of tracking data over time to see trends [10:15];
DEXA scans in 2011: swimming, lifting, and a carb-restricted diet [12:45];
DEXA scans 2012-2014 during Peter's time on a strict ketogenic diet [18:30];
Blood biomarkers for evaluating metabolic health [25:15];
DEXA scan in 2020 after several years of regularly engaging in time-restricted feeding and prolonged fasting protocols [28:45];
DEXA scan in 2021: shifting focus to adding muscle, high-protein diet, and more strength training [40:00];
DEXA scan in early 2022: eating additional calories and adding blood flow restriction (BFR) to his workouts [44:45];
DEXA scan in late 2022: a dramatic change following shoulder surgery, and the impact of stress [48:30];
Peter's approach moving forward following his most recent DEXA scan [59:15];
A rundown of the various nutritional methods of energy restriction [1:06:15];
Current thoughts on fasting and key takeaways [1:09:45]; and