Peter Attia, a former surgical oncologist at Johns Hopkins, critiques modern medicine’s treatment-over-prevention focus after seeing 16 daily gunshot/stab wounds in Baltimore. His 2004 mortgage risk modeling predicted the 2007 financial crisis but was ignored; others like Michael Burry profited by shorting loans. Now, he targets longevity—combining ketogenic diets with PI3K inhibitors to halt cancer progression, dismissing carnivore diets as unnatural despite their psychological appeal. Attia’s rigorous exercise routine (10+ hours weekly) prioritizes eccentric strength training and spinal decompression via deadlifts, aiming for peak function at 80. On COVID, he favors fluvoxamine over ivermectin due to trial inconsistencies but acknowledges monoclonal antibodies’ rapid efficacy, like Rogan’s unvaccinated recovery. Both reject containment strategies, arguing resilience is key as SARS-CoV-2 persists indefinitely. [Automatically generated summary]
And then, but then one of the women said, before we begin, I would just like to state that our land, the land that this building sits on was actually once owned by or, you know, and she rattled off 17 tribes.
Give me some volume on this because it's so stupid.
unidentified
And lots in store for you.
First, we want to acknowledge that the land where the Microsoft campus is situated was traditionally occupied by the Sammamish, the Duwamish, the Snoqualmie, the Suquamish, the Muckleshoot, the Snow Homish, the Tulalip, and other Coast Salish peoples since time immemorial.
A people that are still here, continuing to honor and bring to light their ancient heritage.
I'm Seth Juarez, program manager of the AI Platform Group.
I'm a tall Hispanic male wearing a blue shirt, khaki pants.
Today we kick off two days of learning more about the latest solutions, exploring how these key innovations can empower you to create great things and connecting with you.
Like, there was a, Michael Knowles had this conversation I watched on YouTube where this professor, this woke professor, was trying to say that we should give back land to native tribes.
And he was like, okay, but which ones?
You got to decide which ones because like the Comanche took it from the Apache, took it from the, and he was like going through the history of it.
It's like, how do you decide?
Like, do you go back?
Well, the Comanche took it from you, but you took it from the Navajo, but the Navajo took it from the Pawnee.
I think the only reasonable equilibrium is mind reading software.
I really do.
I think the reasonable equilibrium is going to be something that allows us to read each other's minds so that there's no confusion whatsoever about what your intent is.
And this person, I don't remember who it was, and I don't remember what, you know, it was in the Independent or something like that, wrote this whole thing saying, intent is bullshit.
Intent means nothing.
And it was so ridiculous because the argument she gave was homicide.
She's like, even if you don't mean to kill somebody, it's still manslaughter.
To which we're all at the same time like, yeah.
And there's a difference between first degree, second degree, involuntary.
That's the dumbest thing ever because like what if someone, if you can be charged with manslaughter, if you get in an argument with someone, like say if you are in a situation with someone and they bump into your car and you yell at them and they get in your face and take a swing at you and you knock them out and they fall and hit their head and die.
You can get charged with manslaughter for that.
That is so much different than breaking into someone's house and shooting them in the face.
And the idea of communication is always, it's always, I want to express my thoughts to you so you can better understand what I'm thinking and we can figure out what's right and what's wrong.
We can hash things out.
We can work on a plan.
If you don't know what the fuck a person really means and you're only going by words, like what are we, are we code now?
Like intent doesn't matter.
Emotions don't matter.
Thoughts don't matter.
Of course it matters.
It's like the only thing that makes us human.
It's so dumb, but it's people taking advantage of what the internet provides, which is this ability to communicate and express outrage and push buttons, right?
So because we have this new ability to do this, there's a lot of bad actors that use that, that use that ability to communicate to find things to complain about that are really not relevant.
They're not really something you should be complaining about.
And if you do complain about it, it's really because you don't have any legitimate problems in your real life.
Well, I think the other thing is there's an insecurity.
Actually, there's an opinion piece in the Wall Street Journal today about this, right?
Which is what was the, the title of the article was something along the lines of why the woke can't take a joke.
And what it basically came down to was the, and this was quoting guys from like 100 years ago making the same thing when it came to jokes about religion.
And the idea was, if you aren't comfortable in your position, you're going to be easily offended when somebody rattles you, when somebody pokes fun at you.
And if you're comfortable, like if I came here and said, oh, hunters are wankers, blah, blah, blah, blah, blah.
Like it wouldn't offend you because you're very comfortable in your position in your beliefs.
And it's like, hey, if you don't like hunting, that's cool.
I mean, it's a weird thing that we're doing right now with words.
You know, this is a strange time where we're trying to ban words and we're trying to change the meaning of words and eliminate nuance in conversations.
And again, we're doing it because of social justice, right?
And the people that use social media to try to enact social justice, which really doesn't change.
It's not really getting anybody justice.
It's just getting the rocks off of these people that enjoy complaining.
And most of them really should be doing something else.
Most of the people on Twitter should be doing something else.
I have radically reduced my amount of time on Twitter.
But every now and then, I open it up and it's like watching a fucking room that's like five by five filled with 400 chickens.
Even outside of that, my roommate from med school, who's a urologist, called me yesterday because he couldn't wait to tell me this ridiculous story.
So a colleague of his, this female urologist who's a badass surgeon, was giving a lecture to the medical school, which is common, right?
You'll always have the surgeon will come in or the doctor will come in.
And before she got up to give her lecture, the dean said to her, I'm not making this up.
This is a urologist giving a lecture to a group of medical students, said, I would appreciate it if you would not use the word penis during this lecture.
One of my favorite videos is there's a communist meeting, a meeting of these student communists, and they're like criticizing each other for various things.
And one of them gets up and tells everybody that please keep the chatter to a minimum and be respectful for people that are easily distracted.
And then another one gets up and they yell out to stop using gendered language because he said, guys, can you guys please do this?
And so he gets up and says, can you stop using gendered language?
It's like, you guys are like LARPers.
You know, it's like live-action roleplay.
Like, you're playing like you're in a different dimension.
You want to hear it?
Here it's hilarious.
unidentified
And to win socialism.
Thank you so much.
Quick point of privilege.
Quick point of personal privilege.
Guys, first of all, James Jackson, Sacramento, he, him.
I just want to say, can we please keep the chatter to a minimum?
I'm one of the people who's very, very prone to sensory overload.
There's a lot of whispering and chatter going on.
It's making it very difficult for me to focus.
Please, can we just, I know we're all fresh and ready to go, but can we please just keep the chatter to a minimum?
It's affecting my ability to focus.
Thank you.
Thank you, Comrade.
Okay, is there a speaker against name chapter pronouns?
Well, I didn't totally miss it because I had a lot of people on that were, you know, six years ago, seven years ago, giving me warnings of like what's going on in the universities.
But I didn't think the spillover would be so broad that it would like really make its way into corporations.
Particularly with corporations, because I thought they weren't going to tolerate that shit because it's going to affect their bottom line.
But then they realize that you can sort of do what Microsoft is doing: placate and play to the woke, and then it will somehow or another help you financially.
But I don't think it does.
You know, Apple's looking pretty good after that fucking commercial.
The squamish and the chumash and the well, hey, just wait, I'm sure they'll come up with their own version.
I don't think they will.
I don't think they'll go that far.
I mean, they're pretty woke, but they seem a little bit more reasonable.
The craziest thing is that all of this is coming through devices that are made by slave labor.
Like, that's, at the end of the day, it's so hypocritical that all these people tweeting about social justice and, you know, all the wrongs of the world, you're doing it on a fucking device that's made by child slaves.
Like, sorry.
You want to buy an iPhone?
You've got to get something that's essentially made by people that are getting slave wages.
They're working 16 hours a day in a building that has nets around it to keep suicide people from jumping off the roof.
That's Foxconn.
That's where they make them.
They don't make them here.
They're not making them in Ohio with folks that are in a union that get paid great wages and benefits and can take care of their families.
Uh-uh.
No.
No.
We want to try to keep the bottom line nice and low.
So in order for you to tweet about social justice, you have to do it on a device that's made by people that are not much better than slaves.
The cameras are incredible, but people look at that green text coming in.
They're like, not doing it.
But if someone like Elon convinced people to switch over to Signal, which is probably better for everybody anyway, to have some peer-to-peer encrypted application.
Individual components used in the fabrication are sourced direct from the chip market as a part of the service.
That means they're from other countries.
We use U.S. companies with U.S. fabrication whenever possible, but that doesn't mean it's from the U.S. Most distributors are based in the U.S. Most, with the exception of large integrated circuits that are made in a variety of countries where those companies do fabrication, U.S., Taiwan, South Korea, Japan.
Well, those companies, at least those countries that they just listed, aren't using slave labor.
As an example of NXP CBU used from their fabrication in South Korea, while we source the chips made from the U.S. wherever possible, chip country of origin is not nearly as meaningful as country of board fabrication, especially when all chips are verified.
Hardware circuits that are driven by free software in the kernel.
Yeah, these kernel motherfuckers, these Linux guys, they start talking kernel and my eyes gloss over.
Watches are weird because it's like there's something about it that appeals to men more than it does to women.
Like, I know there's a lot of women that are watch collectors, but it seems if I'm paying attention to the internet and watching videos, it's a male-dominated jewelry thing.
And then as no one has any idea what the time it is.
But as time moves forward and we get closer and closer to modern era, there had to come a point in time where they decided, all right, this is what noon is right here.
Because we're, instead of looking at actual time, which is a thing that's existing right now only, there is the past and there is the future, but actual real time is just this.
You can measure how long things take, but is it confusing us as to what time actually is?
Because what we're really doing is measuring time on devices.
We're measuring seconds that go by, hours that go by, minutes that go by.
It's not giving you an excuse to not be prompt, but it's really kind of bullshit.
I think once a month is reasonable, as long as you really do take time and you make a lot of shots and you have good form and you're really paying attention to what you're doing, you know?
I think there's just too many people that have a gun and think that they're safe and they don't know how to use it at all.
They don't practice with it.
Like, it's really kind of strange.
You could just buy a gun.
Like, you don't really have to have, like, to get a concealed carry permit, you have to show competency.
But you don't really have to do that for a regular.
I mean, the first time I bought a gun was in 1994 when I first moved to California.
And I just walked into a gun shop and I said, I want to buy a pistol.
So I bought a Glock.
I still own it.
And I paid for it.
They did a background check.
I think it was like a few days.
I got the gun.
That's it.
You don't have to know shit.
I mean, I shot it at that range, but you don't really have to know much.
And when I shot at the range, nobody taught me how to shoot it.
I just shot it.
I just like, okay, you put the bullets here and this is where the trigger is and point it down there.
And now, at least with YouTube, like there are some people out there putting really good content out where you can, if you're a newbie, you can say, okay, well, show me how what's the right technique?
You really should get, I think you should get one-on-one instruction if you can afford it.
I don't know how much it costs to get someone to teach you how to shoot a gun correctly, but someone should show you how to hold it where to place your hand and where you should put the pressure and which hand should be relaxed and how to line your sights up correctly.
That's something that's a little tricky to do in a video, you know.
But this is a gun that you can work your way out to shooting a mile, you know, shooting a dinner plate at a mile, which is just, again, that to me is the joy, right?
Like that's the fun is learning the wind and learning the technique.
Because it is in the sense like archery.
You know, in archery, if you can't control the pressure of your hand on the riser, you know, at 20 yards, it doesn't matter, but at 80 yards, it matters everything.
And it's the same thing with those guns.
Like, you know, if you're not on the clavicle the right way and your face is not on this the right way and your trigger isn't pulling back perfectly, like all of that stuff just amplifies mistakes.
So for me, that's the most fun thing is those otherwise not particularly helpful long-range rifles.
It's like, what do you, like, I kind of feel like you could just close your eyes and draw back and launch into the sky and you might hit something.
You know, I mean, there's so many deer out there.
It's for people who don't know what Lanai is, it's a very small island in the Hawaiian Islands chain, and it has 30,000 deer on it, which is so crazy to say.
It's like, you know, in Australia, they've made giant mistakes with that where they brought in other animals to try to tolerate, to try to mitigate the number of, you know, this or that.
And then those animals wind up wiping out native populations of nesting birds, like cats, like feral cats in Australia.
I mean, at this point, you know, Jake Mews, my friend who runs that company out there that's Maui Nui Venison, these guys that are making, you know, commercializing, they have a USDA-grade commercial program for making Axis deer.
And they're about as efficient as they get.
He does not think they're not even going to be able to flatten the population curve till 2030.
I mean, if you go to, I assume, and by the way, I should just disclose, I'm an investor, but Maui Nui Venison, if you just, I think you just heard that?
If you want to think about an ethical way for you to consume meat, if you're one of those people that doesn't want to buy factory farm meat, get some of that.
I can't, I mean, next to hunting, that is about as good as you can get.
But so I take it and I bring the internal temperature up to 120 degrees and then I sear the outside on a cast iron pan.
I usually do maybe a minute and a half on a really hot cast iron pan with beef tallow.
I use grass-fed beef tallow.
And then I pull it, I let it rest, I slice it, and then my family, we ate a lot of it, and then the rest of it I put in like a Tupperware, and then I'll eat it throughout the week.
Because in the morning, that's hard for me to get everything in, all the stuff that I do and work out.
And then I'm pretty religious about my sauna and cold plunge.
So I'm doing, I have to allocate 40 minutes to that.
And so between my workouts and everything, and I'm getting up at 7 in the morning, and then I'm out here doing the podcast.
I got to get everything in.
So I want a meal that I can just pull out of the fridge.
That's the only thing that's missing from wild game is the fat content.
So you got to get your fat content from somewhere else.
And I'm changing my diet a lot lately.
And I've basically decided that my love for pasta and my love for bread and sugar, it's not worth it.
Like when I go long stretches of time without eating that stuff and then I eat it, the impact is so tangible.
It's so obvious.
But it's so casual when you eat it all the time.
When you eat it all the time, you're always eating bread.
You're always eating pasta.
It's like you're used to feeling like shit.
But if you go like three or four weeks with just eating like, I'll eat like potatoes, tubers, I'll eat meat, I'll eat salads, like, you know, salads with, I almost always just have olive oil and some sort of a vinaigrette, some sort of vinegar.
And when I eat like that, I feel so much better.
So I've decided like I'm not going to eat any other way anymore.
Like I will give myself like one cheap meal a week, but the rest of the week, I'm not eating like that.
Like last night, somebody brought cheeseburgers from Golden Tiger to the show at the Vulcan, and I was like, I'm not eating that.
Loophold has, for people that don't know what we're talking about, loophold has a range finder that you put in the weight of your arrow, the weight of the bow, the length of your peep sight.
And they really took care of me because I had the, I don't know which one.
I had one that was like came out a few years earlier and it was okay.
And then it just stopped working one day.
It like literally wouldn't, it would only range something that was perfectly dark, but anything that had like even a bit of brown in it wouldn't range.
And I sent it back to them and I was like, hey, can you guys fix it?
And they're like, they just sent me a full draw four, no charge.
It's kind of wild that someone figured out that you could shoot a laser at something and then it'll report back to you how far that laser is touching something.
Yeah, for people who don't know what we're talking about, because we went into the full archery nerve mode.
Angle compensation means if you are shooting 50 yards, right?
If the object is 50 yards, but it's 50 yards uphill, you will really be shooting more for like probably 57 yards.
You have to, because you're fighting against gravity.
And if you're shooting downhill 50 yards, you're really probably shooting 20 yards because you have no problem with gravity.
It does non-existent.
So you have to use an angle compensating rangefinder that tells you based on how you're turning the rangefinder which direction it's going, whether or not you need to add or subtract yards.
And the first shot I ever took in my life at an animal went a foot over his back because I had been doing all my practicing with a compensated rangefinder.
And this was out in Molokai.
And it was an Axis deer.
And my guide is behind me.
And he ranges it, but he is using an old school rangefinder that doesn't have angle compensation.
But I left medicine in 2006 and went, you know, did finance and other stuff and completely went away from it until I kind of came back to it about 10 years ago.
In cancer surgery, you're doing kind of like very heroic operations.
I mean, the most technically challenging types of operations.
But, you know, half the people still die, right?
So 50% of people who are going to have surgery, and in some cases, more.
If you're talking about pancreatic cancer, 80% of the people whose pancreas gets removed for cancer are going to be dead in five years.
Wow.
So, you know, I just felt like in all regards, I just felt like there wasn't enough in the way of prevention.
And in some ways, that is necessary.
I mean, because I trained at Hopkins, which is in the inner city, it's a lot of trauma surgery.
So every third night for five years, you're taking care of gunshot wounds.
And we had so many.
I mean, Baltimore averaged, at Hopkins, we averaged at the time, I don't know what it's like today.
At the time, it was 16 penetrating traumas a day.
So 16 gunshot wounds or stab wounds a day.
So as a trainee, that's amazing, right?
Like that's that's what you're there for.
That's why I went specifically to that program was to be able to learn to operate on people who are shot or stabbed.
But, you know, it does take its toll on you, right?
You just feel like there's no end to this.
Like, I mean, it's a war zone out there.
And yeah, I mean, I remember there were times when, you know, you'd be a part of like a heroic rescue of somebody and they go out the door and they come back a week later with a gunshot wound to the head and they're dead.
And you're like, oh, I mean, come on.
So yeah, I was just frustrated with everything in medicine when I left.
I was super pissed.
My wife was like, you know, you bitch and moan about this so much.
And I was like, well, I can't fix it, so I'm leaving.
So I left and joined a company called McKinsey and was recruited there to do healthcare, but ended up because my background's in math doing credit risk.
And this was right as this was like the two years building up to the mortgage meltdown.
Yeah, I mean, that's a really good question because at the time, in November of 2007, we and I want to also be clear.
The reason we knew with such clarity how bad this was is we were work we had a client.
Our client was the largest, I guess I could say, probably the largest U.S. home lender in prime real estate.
And we had all the data.
So we're able to see stuff that's not publicly available.
But they didn't see it.
But when we went back and looked at the analysis, we figured out that every that starting in 2004, starting in the second quarter of 2004, every loan that was being originated was behaving differently than the entire history of mortgages.
So this is a really interesting analysis.
It's called a vintage analysis.
If you bundle mortgages together and look at how they behave, for all of time, they behave in a certain way.
For about the first 18 months, none of them default.
So 18 months after a person buys a house, historically, there's no chance of default.
Then defaults start to rise.
And they rise for about the next two to three years.
And then they never default again.
So the vintage curve looks like this.
This is cumulative loss rate.
So what's the reason for that?
So the reason nobody defaults in the first 18 months is because historically, you really make sure that the person who you're selling a house to or giving a loan to can afford it.
You do a really extensive background check on them.
And if something's going to go wrong, it's unlikely to go wrong in that first 18 months because of how much you've documented their income and employment and stuff like that.
Then you get into an area where some people are going to default.
And then the reason three, four years out, there's no more defaulting is because by that point, people have enough equity in their home that if they run into trouble, they can always sell the home and the bank gets their money back.
So again, you go back in time, every vintage curve for every single mortgage looked like this.
Really boring.
We went back and plotted all the vintage curves going back to the year 2000, and they all looked doo, doo, doo, doo, doo, doo, doo.
And then in Q2, 2004, so you plot these in three-month vintages, they started doing this.
Meaning they started to, instead of going up and then flat again, they just kept going up and up and up and up and up.
But they actually did it at an exponential rate.
So they didn't just go up straight.
They would go up exponentially.
In other words, there was no end in sight to the explosion of losses.
So the losses started happening immediately and they never slowed down.
They accelerated with time.
So this is looking at a chain reaction.
And this was one of five models that we built to try to understand what was going on.
And they all pointed in the same direction, which was catastrophic outcomes, basically for loans that became originated after 2004.
So by the time we're in 2007, when we show all this data to them, obviously they didn't believe it, right?
They said, well, because the punchline was horrible.
The punchline was, you're going to lose more in the next 18 months than you've made in the last 10 years.
And that was like, you know, they were like, that's not possible.
And I had to be the one to tell the head of the bank, right?
Because even though I was only like, there's a hierarchy at McKinsey, there's like senior partners, junior partners, and I was just like a lowly manager who ran the analysts.
And the senior partner would normally be the one to present such an outrageous finding to the board of a bank.
But he was like, you should present this.
And I said, why?
And he goes, well, you understand the technical details of the model better.
And also, you used to be a cancer surgeon.
So you're used to giving bad news.
I think this is not going to go very well.
So you do this.
And it did not go well.
It was not well received.
They could have done something.
Yes, they absolutely could have done something.
It wouldn't have stopped all the damage, but it would have minimized the damage.
Because remember, there was still another 10 months of horrible loans being originated, horrible loans being securitized, and they were mispriced.
I mean, ultimately, that's the problem with this.
It was just a mispricing game.
They didn't know how to price the risk of the loans they were making.
It was actually super accurate in terms of describing what was going on.
And I remember when it came out, I was able to finally explain to my wife why we weren't billionaires.
Because she was always like, dude, you knew this was happening, and yet, like, why do I hear about guys like John Paulson and all these hedge fund guys that made $3 billion on this?
And I said, ah, this movie will explain why.
If you know this is happening and the only instrument you have in your mind to make money on it is shorting equities, you can't make money.
Right.
In other words, and by the way, ethically, I couldn't have done this because I had inside data of a bank.
I couldn't have done anything with that information.
But let's just assume that I could have shorted all the other companies.
But I could never have shorted this company that I knew inside and out.
But I could have shorted others.
But even still, I wouldn't have made a lot of money because one, shorting equities is really expensive when you don't know when the shoe is going to fall.
Because you have to make a margin call over and over and over again.
It's not leveraged, right?
What these brilliant guys did was they figured out that they could short an option on what was going to happen.
They could basically short an insurance contract.
And that was super cheap.
You're leveraged 1,000 to 1 at this point, meaning you only have to put a dollar at risk to get $1,000 back on something you know is going to happen.
And you don't have to really concern yourself with exactly when it's going to happen.
At least not in the same cost-inefficient way that you have to with equities.
When the whole thing blew up, people said, well, this is because interest rates have been too low for too long.
So Alan Greenspan became the very convenient bad guy for all of this.
And it's true.
Interest rates were a little bit too low for too long.
But we know today that that's categorically not the thing that drove it.
Low interest rates are simply the oxygen that's necessary for a fire.
But we're sitting in a room right now with lots of oxygen.
There's no fire going on.
Clearly, oxygen is not the root cause of the problem.
The root cause of the problem was the absolutely inept lending standards.
What fostered it was the ability to securitize loans.
So once you could make a horrible loan and you didn't have to live with it on your books, you could actually sell it to someone else who didn't understand what you were selling, then it just became out of control.
The collateral damage of that would have been devastating.
But your other point is also notable.
So let's not confound two things.
So if you let the banks fail, everything goes to hell in a handbasket.
You have a recession that rivals that of 1929.
That's a bad scenario.
The way that the TARP program was engineered was to prevent that from happening, but also it wasn't a gift.
It was, you're going to pay these loans back, which they did.
But there still, in my opinion, could have been and should have been more clauses in that program that permitted some of the really flagrant abuses that came down the line, like, you know, the AIG guys getting bonuses that they probably shouldn't have got.
In other words, I think the government basically made the argument, which was, well, if we don't pay these people, they're not going to stick around and we need them to clean up this mess.
And my view is, I bet enough good people would have stuck around without having to pay so many people so much.
And by the way, the people that really needed the bonuses were not the CEOs.
Well, the most common genetic driver of heart disease is something called LP-little-A.
So one in about 10 people, somewhere between one in eight and one in 12.
So call it one in 10 people.
10% of people have a gene called LPA that makes too much of this lipoprotein called LP-little A. You've heard of LDL, right?
So LDL is this atherogenic lipoprotein.
LP-little A is an LDL that has another protein wrapped on it called apo-little A, and it makes it much worse.
So the single most common genetic cause, the single most common hereditary driver of cardiovascular disease is elevated LP-little A. And the tragic thing is most doctors don't even know what it is.
So this is one of the things I have more podcasts on this topic than any other because it's inexcusable to me that a patient doesn't know that they have an elevated LP-little A. This is a screening test we should do on children.
So that's number one.
After that, it gets much more complicated.
Heart disease is wildly polygenic.
So LPA is one rare example that's not polygenic, meaning there is just one gene that drives LPA.
But when you start to get into something like familial hypercholesteria, which is also kind of common, that's any set of genes.
And there are over 3,000 mutations that produce elevated LDL through one form or another.
That becomes another huge driver of genetic inheritance.
But what's scary, at least for someone like me, is it's really clear when you look at my family history.
Heart disease is a problem.
I don't have anything recognizable, meaning I don't have LP-little A. I don't have familial hypercholesterolemia.
I don't have any of the few known genes that are really driving this.
My cholesterol levels were never really that heavy to begin with.
My LDL, which is kind of an irrelevant, stupid metric anyway.
But even if you looked at my ApoB, which is the metric you're supposed to be looking at, was never through the roof.
But when I was 35, I went and had a calcium scan.
So it's a CT scan, looks at your heart.
And I had a score of six.
Now, six is not a high number on a calcium scan, but when you're 35, that places you at the 90th percentile.
So that was like the, I got to figure this shit out.
Like, I'm going to devote the rest of my life to understanding how to not die of heart disease.
And then ultimately, so my first focus became an obsession with cardiovascular disease, which lasted about four years.
And then I realized, like, well, there's no benefit in not dying of cardiovascular disease if you're going to still die of cancer or dementia or something like that.
So then my obsession and interest just expanded through all of that.
Well, for one, of the big diseases, it's the one for which I think we have the least idea of what the risk factors are.
So the big three in terms of death is atherosclerosis, cancer, and neurodegeneration.
With cancer, it's also very polygenic.
And what's that mean?
Lots of genes are involved.
So if I did a genetic test, if I had your entire genome in front of me, it wouldn't tell me much about your risk for cancer.
So the genes that are driving it are also not germline.
They're somatic, meaning they're inherited mutations.
So, one of the few things we know about cancer is the earlier you can detect it, the better.
That's a truism that is becoming almost impossible to argue.
So, you're always better off finding a cancer when you have 100 million cells that are cancerous versus 10 billion cells that are cancerous.
And our tools for screening are somewhat limited.
Now, they're getting better.
So, to your question earlier, what's one of the things I'm excited about?
I think liquid biopsies are something in the last year that we have become very excited about.
So, all of our patients get these things called liquid biopsies, which is a blood test that measures something called cell-free DNA.
So, we're looking for tumor DNA in the bloodstream.
So, meaning at very low levels of tumor burden, you can still pick it up by getting some of this cell-free DNA floating around your bloodstream.
So, if you do, it's literally like you take a tube of blood and you can say, oh, there's actually like some pancreatic cancer here or some colon cancer here or breast cancer here.
But every time I go and get this diffusion-weighted image MRI, which is this very particular type of MRI that's uniquely tuned to detect cancer and getting a blood test like this or getting a colonoscopy, which I'm very aggressive with, all of these things, yeah, there's always a moment of just let me come out clean.
I just, there was nothing else I could think about.
Like at the time, I had left that one company where I was doing all the energy stuff or where I was doing all the finance stuff and I went to join an energy company.
So now I was like working on like a renewable form of oil.
I think she must have been talking to a normal voice.
But here's what interested me.
I sat down in the office and she pulled out a black box that was, I don't know if it was called Edison at the time or if it was the precursor to what would become Edison.
Diagnostics is not something I knew a ton about, but I'd spent two years at the NIH and I certainly understand how chemical reagents work and I understand how chemical assays work.
And I know how, for example, an ELISA works.
And ELISA is a type of assay that you do to measure something, but it requires a lot of washing and rinsing and repeating.
And I know that many biomarkers that are of interest, for example, something like insulin, if you want to measure a person's insulin level, you have to do these types of assays, right?
So I was saying to her, you know, Elizabeth, I don't understand how you could put a drop of blood in here and get anything out that's more interesting than glucose, hemoglobin, sodium, and potassium.
The really simple things that can work, you know, that can be measured off a drop of blood.
And she kind of gave me some answer, and I said, well, can I see the inside of the box?
And she said, absolutely not.
And I said, well, I've signed an NDA.
You know, I had to sign an NDA to get in the building.
So she was like, nope.
So I just decided I wasn't interested in the company because I couldn't get sort of straight answers from her.
I remember one day saying to my wife, because she was on the cover of Forbes, and the company was valued a little over $9 billion.
And I said to my wife, do you know how much we would be worth if I had taken that job now?
And she's like, how much?
And I told her and she's like, good God.
And so I'm at the Vanity Fair event in San Francisco.
I didn't know it at the time.
This was a week before the Wall Street Journal article would fall, John Carrio's article that was the one that kind of unraveled all of Theranos in October of 2015.
They pretended that they got a document from Pfizer.
put pfizer's name on a document and it was an internal document and it was a basically substantiating the machine the edison machine and all the possibilities that it could she also lied about military use uh there was The Department of Defense contracts.
Yeah, they have her on the stand lying or have her on the stand admitting that she lied.
So the beginning episodes of the dropout all detail the scam and all detail all the stuff that was going on.
The people that were working, they were slowly figuring out, like, what the fuck are we doing here?
And then it went away for a while and then came back during the trial.
So now it's detailing all the things that the prosecution is finding.
Also, it must be, no, it's not the civil trial.
It is the current trial because they were specifically discussing these documents that they had put Pfizer's label on.
So they made it look like this document was coming from Pfizer, like saying, oh, this stuff is amazing.
But really, it was just internal from Thuranos.
It's wild.
One of the things that I love about it is I'm always fascinated by con artists and cult leaders and people who manage to pull the wool over people's eyes.
But when people do it in a clumsy way and still get really far, like she was clumsy.
She wasn't just a little clumsy.
She was like, she was a, it was, I, you know how I got obsessed with this?
This is really weird.
She was giving a speech, and this was before I had any idea that there was anything wrong with the company.
Before she got caught, she was giving some speech at some women's women's group, some like, you know, exceptional women were all getting together and they were all, you know, and she gave us this speech.
And the speech was so bad that I was fascinated.
I was like, that's a moron.
Like, this is not a smart person.
Like, this is a dumb, clunky speech.
Because I'm a professional orator.
I mean, that's what I do.
I talk, you know?
And so when I see someone that's talking and she's basically, these women are amazing.
Oh, you amazing women.
I'm just so pro amazing women.
Is that the speech?
Let me hear this dumb speech.
unidentified
Dana asked, I am so incredibly humbled and so honored to be with this incredible group of women.
I want to just take a minute to say, especially to the young women in the room here, do everything you can to be the best in science and math and engineering.
It's our actions that will determine this new stereotype around women being the best in science and technology and engineering.
And it's that our little girls will see when they start to think about who do they want to be when they grow up.
But when you heard Steve Jobs talk, Steve Jobs had a vision.
Here's my vision.
This is what I think can happen.
And he would talk, and you go, well, that's a brilliant, completely obsessed man.
Like, this person is very brilliant.
And it makes sense that this is the head of this incredibly innovative company.
When I heard her talk, I was like, who's this idiot that you have talking?
Like, this is not a person that spent a lot of time thinking, right?
Like they, if you went to college for a long period of time and really worked on your, you know, your grammar and your understanding of the correct use of language to inspire and challenge people's ideas, that's not the fucking speech you'd give, right?
They wanted to believe that there was this female wonder kind who left Stanford at 19 years old, dropped out of school and figured out this amazing technology.
And along the way, became, at least until she got busted, the richest self-made woman ever.
Whenever someone comes to me, like some guy came to me with some crazy, I mean, I don't know if it's real, so I don't want to talk about it, like say it specifically, but if it's true, it sounds like this guy's going to revolutionize a form of travel.
Like if stress gives you cancer, imagine the stress of like duping people out of 9 billion, and you're sitting around knowing that your voice is fake, and you're wearing a black turtleneck, and people that you went to college with are like, hey, that bitch doesn't even talk like that.
I hear the text messages between her and Sonny were pretty funny.
Because I read an article that said, if you really want to incentivize people to not commit crime, just let them know that all of their cheesy text messages are going to be made public.
Well, I think what was interesting for what she was providing was Safeway was going to buy into it.
Was it Walgreens?
Yeah, Walgreens.
And so Walgreens, I believe, backed out.
I think they realized somewhere along the line that she was full of shit.
And there was some text messages and emails that they read out from the CEO because he had retired before it ever came to fruition and then they backed out of it.
But Safeway wanted to put them all in the stores.
And so you could be able to go shopping for food, get your blood taken, a little tiny pinprick, and find out if anything's wrong with you right there and then.
But again, it still comes down to having somebody that can actually tell you what's wrong.
And by the way, the stuff that was relevant, it's not like they're going to measure LP little A. It's not like you're going to tell you your ApoE4 status.
It's not like they're going to tell you, like, of the 10 most relevant things that I would look at in somebody's blood, they weren't measuring any of them.
It definitely makes you more susceptible to Alzheimer's disease.
But it's a little, you know, today we know it's more nuanced.
We know that there are other genes that can be protective and can completely abrogate the effect of APOE4, which is the, that's the, that's the gene that's the more risky one.
It is not remotely common as far as the leading, you know, I mean, breast cancer is obviously a pretty common breast cancer, as a pretty common cancer to women.
You know, I would guess that 5% maybe would be BRCA-associated, if not less.
So if you and I were killed in a car accident tomorrow and they took our prostates out and sectioned them up, the likelihood that they would find prostate cancer cells in one of us is at least 50%.
This is a technique that was pioneered by a guy named Pat Walsh at Johns Hopkins in the 1980s.
And it wasn't that taking out the prostate was hard.
It was taking it out while preserving sexual function was really hard because the neurovascular bundle of Walsh, which now bears his name, which is what controls erectile function, wraps around the thing you're trying to cut out.
So the goal is to basically identify a guy with prostate cancer who has the variant that's going to spread.
So today, this has been, I mean, there's been so much progress in this field.
So we use a blood test called a 4K score.
So you know what a PSA is?
You've probably had your PSA checked a bunch of times.
So PSA by itself is not a great blood test.
You have to use more information than just the PSA.
You have to know the PSA velocity and the PSA density.
So the velocity is what's the rate of change of the PSA, and the density is dividing the PSA by the prostate volume.
So if you get an MRI or an ultrasound, you can tell the volume of the prostate in grams or the volume, and then you can turn it into grams.
So you normalize PSA to volume or mass, and you have a density.
And those two things become more suggestive.
So once the PSA starts to look a little bit suspicious, and once it gets over about four, we do this 4K blood test, which is another form of liquid biopsy.
And that gives you a much more interesting number.
It basically tells you what's the probability that this person is going to have metastatic prostate cancer, not just prostate cancer.
And if that 4K number is above a certain threshold, I think 7.5%, the probability that they're going to have metastatic prostate cancer approaches 85, 90%.
But the stuff I had to give up, like even one of my favorite things is stir-fry.
Like, I love huge curry stir-fry that I make.
And even something that's that, it's just vegetables, but it was still too much to keep in, it was too much carbohydrate to stay in ketosis.
So I just kind of missed.
And also at that point, I was switching more from ultra-distance swimming and stuff into shorter distance swimming.
Like I was doing more, you know, pool racing and more just shorter distance stuff.
Also on the bike, I was becoming going less from kind of ultra distance bike stuff to like a 20 kilometer race or 40 kilometer race.
So as you move towards that new energy system, you just need more carbohydrates.
But anyway, to your question, I think there's an awesome theoretical argument for it, but it's also important to understand that even when you're on a ketogenic diet, your glucose isn't zero.
So it's all about probabilistic reduction, right?
You know, it's keeping insulin lower.
That probably has a greater effect than keeping glucose lower.
Because if you're on a ketogenic diet and you're not on a ketogenic diet, we're talking about a difference of one millimolar in glucose.
So it's probably more the presence of the ketone, the reduction of the insulin, if anything, that's having a role.
What I think is most interesting is not just a ketogenic diet.
It's when you combine it with a drug called a PI3 kinase inhibitor, which is a drug that blocks a very important pathway for cancer to grow, but has one escape valve, which is it raises insulin.
So that's a bad thing if you're trying to minimize cancer.
So when you combine a ketogenic diet with a PI3 kinase inhibitor, at least in animal studies, which is about the extent of where this has been studied so far, the results look really good.
Because PI3 kinase inhibitors by themselves have not panned out, even though theoretically they should, they should be amazing for cancer.
They haven't been great.
And it's been speculated that that's because of that escape valve, which is it pops off to a higher insulin level.
So when you layer on top of that a ketogenic diet, it seems to work really well.
And anecdotally, one of my good friends from med school, his wife has metastatic breast cancer.
She was diagnosed, God, probably seven or eight years ago.
So metastatic breast cancer is a death sentence.
It's unsurvivable.
She was enrolled in a clinical trial in Boston that was using PI3K inhibitors.
And so she got one of these drugs.
She's the only woman to this day that's still alive.
No, she literally has this one little foci of metastatic disease in her hip still.
So this one little nubbin of potential cancer inside her hip bone, but it's stayed static.
I mean, it's causing some structural issues.
She, you know, obviously her hip's weaker, but it's kind of amazing.
And her story is actually kind of one of the things that's got some of the people who develop these drugs thinking about this idea of combining ketogenic diets with PI3K inhibitors to try to squash the insulin level and minimize basically that escape route for cancer.
So the reason I stopped taking it three years ago, I took it for probably eight years, but three years ago I stopped because it does impair mitochondrial function, at least at the level that I can measure it.
So I measure my lactate levels when I'm exercising in a certain type of exercise every day.
And I'm basically trying to generate the highest amount of power I can generate on a bike while keeping lactate below two millimole.
And that's like the limit of my mitochondrial throughput as my kind of my maximum aerobic efficiency.
And when I was on metformin, I just noticed like I was hitting that lactate level higher than I believed I should hit it, just based on my fitness.
I mean, the hazard ratios for each of these are pretty interesting.
This has become like each year I try to bring one new focus into our practice.
And the past 12 months, the focus has been entirely around taking exercise to a new level in terms of our understanding of how to fine-tune it.
And the data are unbelievable, right?
So if you everybody knows that if you smoke or have diabetes, your risk of death goes up a lot.
But your risk of death from having high cardiorespiratory fitness goes down by much more than your risk of death goes up from smoking or diabetes.
So smoking and diabetes will double or triple your risk of death, depending on the timeframe you're looking at.
Having very high cardiorespiratory fitness, so having a VO2 max that is elite, we would define that as the top 2.5% of the population compared to below average is a five-fold reduction in all-cause mortality.
And then when you layer in strength and muscle mass, we actually now have pretty good data as to the fact that strength is more important than muscle mass.
We just use muscle mass as a good proxy for strength, but if you just focus on strength, that's the metric that matters.
It's about a three-fold reduction in all-cause mortality when you compare high strength to low strength.
And the tests are, you know, we're talking, it's not like how much you can squat and deadlift.
It's like grip strength, dead hang, how long can you do like an air squat?
You know, like what's your quad strength?
How quickly can you do five reps up and down from a chair?
I mean, it's relatively simple stuff.
But when you stratify people by those metrics and you compare the highest to the lowest performers, there's just no comparison.
On the strength data, we don't see it because the data have only been parsed out as high to low.
On the cardiorespiratory, there is a point of diminishing return.
So remember I said elite is the top 2.5%.
And then you, so we break them into five categories, but they're not equal in bucket size.
You get most of the benefit, honestly, by going from not fit at all to average fit.
That gives you three of the 5X.
Now that said, I hold myself and my patients to a way higher standard, which is we have a chart that shows all the data by age, by gender, and by VO2 max.
And I would say, if you're a 52-year-old male, I'm asking you to have the VO2 max of an elite 42-year-old male.
So I want you to be a decade younger elite.
And then we do the same thing with strength metrics.
And when you prescribe that, like say if you take a 52-year-old male that doesn't have a history of cardiovascular activity, maybe they lightly work out the gym or something like that.
What particular exercises do you think are the best to achieve that result?
Like what is – For zone two, I mean it really just matters that you're consistent.
But I think most people find you can do a higher output when you're on an air bike in terms of absolute wattage because you are leveraging upper and lower body.
And as you get heavier, it must get you like your hand strength must really need to be a giant factor.
If like you're dealing with a guy who should be 170, well, like if you decided to bodybuild and you went to 250, that would probably radically decrease your about.
One is I used to think it was the obvious reason, which is look at the causes of mortality.
We have this thing in our practice called the death bars.
So one of my analysts, Bob Kaplan, about a year ago, I said, Bob, I want you to make these five graphs for me.
And they're basically everything about the causes of death.
So one of them is just show me all cause mortality by decade.
Now break it down into the subsets.
And one of the most common things is accidental deaths.
And this is the most interesting trend is accidental deaths change so much by age.
So in our age group, so by the way, accidental deaths are uniform across the population, but they become a much bigger source of death on a per capita basis as you get older because there are fewer older people.
In our demographic, most accidental deaths are overdoses.
When you're older, they become virtually all falls.
90% of accidental deaths are falls.
Fall is a very lethal thing by the time you're 75.
Like you and I don't think about it.
By the time you're 75, falling is a devastating consequence.
So think about how strong grip versus weak grip would impact your ability to tolerate a fall.
It's, can you get your hand down?
Can you grab something when you're falling?
All of those things matter a lot.
The second reason I think grip strength matters a lot is it is such a good proxy for strength.
Because one of the things I've learned in the past year, becoming so obsessive with grip strength, is how as my hands have gotten stronger, it's alleviated all the shoulder.
Like I have a torn labrum here from my swimming days that is so painful.
I thought I would never be able to do a dead hang pull-up again.
Because whenever I was in this full position, I'm putting so much stress on the labrum.
So I would just, I was doing pull-ups to here, right?
Like I would, you know, I'd go from here to here.
And then Beth Lewis, this person in our practice who is kind of like our strength guru, she was convinced that if I could just get my grip stronger, I would fix this.
And I was like, Beth, that doesn't even make freaking sense.
Like, why does having more grip fix my shoulder?
But I just started doing everything she said, like all of these dead hang finger exercises and all this other stuff.
And now when I do a pull-up, I can dead hang with zero pain.
And I'm just putting all this extra pressure in my finger.
And I think the reason is it is allowing us to potentiate force more stably from our scapula all the way through.
And so much of the instability we have in shoulders and all these injuries is just because we don't transmit force correctly.
So I think something about having really strong grip just basically fixes so much of the upper body strength, you know, weakness, you know, strength imbalances that we have.
And again, it's a proxy for people who don't fall.
It's a proxy for other things.
It is a proxy for muscle mass.
The more muscle mass you have, the more glucose you dispose of, the more metabolically healthy you are.
No, I haven't, but I've heard great things about it.
But I wanted to ask you this before I forget.
You had written something once about, I meant to talk to you about this, about deadlifts actually decompressing the spine, which I found so counterintuitive.
So how does that work?
Like, how are you getting deadlifts to decompress you?
It's much easier with a hex bar deadlift than a sumo deadlift or a dead way.
Yeah.
So the reason is if you have enough intra-abdominal pressure and you're putting your spine at just the right amount of extension, you're actually extending your spine when you lift because of the position of your hip.
So it's hard to explain without feeling it.
And it took me a really long time to feel this.
But have you heard of dynamic neuromuscular stabilization?
So it's this discipline that really taught me how to do this kind of intra-abdominal pressure where you put a huge amount of pressure in your pelvis, basically.
So you're like, you ever notice how the really good power lifters have huge abdomens?
And this is a big part of it is they can generate so much pressure in their abdomen that they're basically stretching out their spine, pushing out everywhere.
So they have kind of a cylinder inside their body, right?
And if you can't do that, you almost have like a triangle in your body with the diaphragm being the top and the pelvis being the bottom.
So the force is not going out in all directions in the same way.
So what you want is this force to be going out equally.
And When I do that with a hex bar deadlift, I can hear my spine like actually like going like an adjustment, just the same as when I'm dead hanging.
This is called your anterior superior iliac crest.
So I go about two finger breadths in, two finger breadths down, and as I'm laying on my back, I'm trying to put as much air into there as possible.
And you want to imagine that your shorts, which have the ring that the waistband of your shorts make, you want to make it as big as possible in all directions.
So you're trying to get air out into your back.
You're trying to get air into your pelvis.
So the first step is just being able to do that.
And then eventually you want to be able to do that while breathing, meaning you want to be able to get that pressure out and then take a breath.
Because at first you won't be able to do that.
At first, you'll just blow out and you'll be holding your breath.
So the next thing you want to be able to be able to hold that while you breathe.
And then we do some other exercises before we would go to deadlifting.
So now you want to be able to get into certain positions where you're on your front and you're in opposite support.
So the obvious one is like a bear position where you're on all fours.
But then ultimately we get into these really complicated positions where you're on one elbow and the side of one knee, but you're keeping your pelvis totally level.
Without even knowing that's why it was called, yeah.
The doctor, it took her a couple weeks to figure it out, but that first thing with like getting, I'm trying to find like this position here where her back is up and her legs are like that.
So you see the one that's four to five months there where she's in an eight, so where her left leg is out?
Yeah.
So that's, to me, that is the gangster position that gets you ready to deadlift.
When you can do what she's doing and now pick your hips up off the floor and stay perfectly level with only your left leg down and your right elbow down, and you'll feel your spine will just go, you're just, you feel this total expansion.
That tells you you have the intra-abdominal control to deadlift.
So the other thing that DNS that I do every day for DNS is, So there are muscles that run on the front of your vertebral bodies and your cervical spine.
And they're called deep neck stabilizing muscles.
And one of the challenges that most of us have who all have sort of cervical neck issues is those muscles aren't strong enough.
They're not fully engaged enough.
So another exercise I do when on my back in that position with the intra-abdominal pressure is kind of look down at my chest and without lifting my head up, go through the initiation of a lift up.
And to do that, you basically will end up using these deep neck stabilizers as opposed to the scalenes, right?
You don't want to be moving your neck or stabilizing your neck with these muscles that are outside.
You want to be doing it with the muscles inside.
And that's what's extending the spine.
You can't feel these muscles.
Everything you're feeling right now is sort of superficial.
And then I turn around, I do it backwards, and then I do it sideways so I have it going to my right side, I have it going to my left side, and then I do what they call the Stevie Wonder.
So I do this thing like this.
And the whole idea is that you're not putting that unnatural hinge on your discs.
And all of this muscle tissue has gotten so much stronger because of it.
My neck is bigger.
I mean, I haven't measured it, but I mean, shirts that I used to wear, I can't fit anymore.