#325 ‒ Peter’s key takeaways on bone health, calorie restriction and energy balance, dopamine and addiction, gene editing, and testosterone therapy safety with a prostate cancer diagnosis | Quarterly Podcast Summary #3
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Hey everyone, welcome to a sneak peek Ask Me Anything or AMA episode of The Drive Podcast. I'm your host, Peter Attia. At the end of this short episode, I'll explain how you can access the AMA episodes in full along with a ton of other membership benefits we've created. Or you can learn more now by going to peterattiamd.com forward slash subscribe. So without further delay, here's today's sneak peek of the Ask Me Anything episode. ♪

Welcome to another AMA episode of The Drive. Today's episode will be the third of what we're calling the quarterly podcast summary. The feedback, again, has been very positive on these, so we're going to continue to do these. And in these conversations, what I do, take the interviews that I've done over the preceding quarter and note the most important insights that I've gained personally from these interviews, along with any changes that have resulted in my practices from these insights.

So with all that said, these shouldn't be seen really as a replacement for listening to these, but I hope they serve as both a primer if you've listened to them, or maybe they direct you to go back and listen to something that you missed. In today's episode, I'm going to cover interviews that I did with Anna Lembke, Feng Zhang, Belinda Beck, Eric Ravison, and Ted Schaefer.

In this discussion, we speak about topics such as dopamine, addictions, CRISPR, gene editing, bone health, the importance of exercise at any age, energy balance, caloric restriction, prostate cancer, testosterone, and much more. If you're a subscriber and you want to watch the full video of this podcast, you can find it on the show notes page. If you're not a subscriber, you can watch a sneak peek of the video on our YouTube page.

So without further delay, I hope you enjoy this special quarterly podcast summary AMA of The Drive.

Peter, welcome to another quarterly podcast summary AMA, which is a mouthful. How are you doing? Good. Do we have an abbreviation for that? I think it's QPS 1, 2, 3. This is 3. QPS 3 AMA 60 something. Yeah. We're just going to keep throwing numbers at it until it sticks. That's definitely not confusing to the listener. Well, thank you for coming to Austin to do this one in person. Yeah.

Yeah, it's honestly weird to not look at you through a screen for one of these. I feel the same way. Yeah, I can't hide what I usually do behind the screen in this one, so this is a much more serious episode.

So for this one, as a reminder for people, because it's still relatively new, what we're doing with these quarterly podcast summaries is we're taking previous episodes and just going through them with your thoughts. And this came about because you take an insane amount of notes through the podcast you have in front of you there. And so we would internally kind of go through these and we did a few of these and people really liked them. And so what we're going to do is we'll go through, we won't necessarily summarize them as much as

You will talk about your big takeaways, and then we'll kind of have a conversation on how that's affected either your behavior, how you deal with patients, anything of that nature. And so for today's episode, we're going to talk about dopamine through Anna's podcast. We have CRISPR, which is super interesting, through Fung's podcast. Bone mineral density, lifting in females, especially as you age with Belinda. Calorie restriction with Eric, which is always of interest.

and then prostate cancer, which was kind of a special shorter episode we did with Ted. So I think it's really good, kind of a huge variety of things that we'll cover. But with that said, anything you want to say before we roll? No, just to reiterate, I'm sure I'll have said this already in the intro, which I obviously haven't recorded yet, that this is not a substitute for going back and listening to the podcast because I'm not even attempting to provide the full context of everything. What I'm really trying to do is capture

What I'm taking away in real time as I'm having these discussions with people, what am I making notes on? That's effectively the filter here is what is Peter pulling out of this as the most interesting stuff? And sometimes that comes with an assumption that other content is understood and heard. So the hope is that you're listening to this after you've heard these podcasts or that you listen to these and maybe go back and listen to a podcast that you skipped because the insight is particularly interesting. Yeah. Yeah.

Definitely. Let's start with Anna's episode, which covered dopamine, great book, super interesting episode. So do you want to kind of start with what your main takeaways were from that episode?

Yeah. So I read Anna Lemke's book, obviously before interviewing her, enjoyed it a lot and was kind of looking forward to talking about this and had a lot of questions about what really constitutes addiction. Because I think the book is really about addiction more than it is about dopamine, right? Dopamine is kind of a heuristic. Everybody's heard the term dopamine. Everybody understands what dopamine is. It's a neurotransmitter. It's one of the most important neurotransmitters in the reward system and therefore in the addiction system, but it's not the only one. And so

And so I think my interest was maybe even personally a little bit less in the nuts and bolts of dopamine and more around the science of addiction. We started with defining the traditional aspects of what defines addiction. So the sort of out of control, compulsive use, the cravings, the continued use despite consequences.

and then the tolerance to the stimulus, and then ultimately withdrawal when it's removed. So again, if you view that through the traditional lens of how people think of an addiction like alcohol, all of those things clearly check, check, check, check, check. But of course, there are behavioral things that show up here as well. Everything from gambling to sex to workaholism. Many of these things can constitute an addiction. Now, one of the things I took away from this that I found interesting was the idea of what are the factors that influence this. In particular, I wanted to really understand how heritable addictionism

addiction was, meaning how much is this written into the genetic code. Turned out quite a bit according to the heritability data. Now again, you'll often hear us talk about these. This came up in the podcast with Carl Deseroth where we talked about eating disorders, depression, schizophrenia. The typical way that these conjoint twin studies are done is they look at the prevalence of a certain condition in identical twins that were raised apart. That's really the best tool we have

to understand how much of a role do genes play. You take two people with identical genes raised in a completely different environment. And based on that, Anna said that addiction is about 50 to 60% heritable. That's a huge amount, obviously, but it's a big enough amount that it can't be ignored, but it's not so big an amount that the die is cast. Meaning just because you come from a line of people who have an addiction to one thing or another doesn't mean that your fate is sealed. So what are the other two

two things that play a role in this. And she described them as nature, nurture, neighborhood.

Nature, genes, nurture, how you're raised, and neighborhood, meaning the environment you're in. Now, she wasn't able to provide, or at least if she was, I missed it, what the percent is for nurture versus neighborhood. But again, if heritability is 50 to 60%, we're going to say 40 to 50% comes from how you were raised. And I don't just mean like the obvious things, but I also mean the subtle things, right?

So are you raised around people that are engaging in a certain behavior? Do you have experiences in life, for example, trauma that might predispose you to certain addictive behaviors? This idea of neighborhood is very important. And I think it really has a lot to do with anybody who's ever considered trying to break a bad habit. So if you struggle with gambling, it's really hard to break a gambling habit if all your friends are gamblers. You either have to get a bunch of new friends

Or somehow just decide you're going to hang out with a bunch of people who gamble but not do it yourself. Very difficult. Another topic that I just found incredibly fascinating, and I don't think we know the answer as the takeaway, is

Why do some people have a certain lock and key configuration for certain addictions? So why is it I use myself as an example? I think in the podcast I really enjoy alcohol like it's not like I'm repulsed by the taste of alcohol I quite enjoy it like literally enjoy the taste I just don't think I could be an alcoholic if I tried in other words if you surrounded me with alcoholics it would never appeal to me to drink in the morning or

to drink in a manner that would lead to excessive use. So why is that? It's clearly not moral superiority. That's not what I'm trying to say. It's that there is something in my brain that doesn't get enough of that cycle from alcohol that it just doesn't work for me that way. The same is true with gambling. I was in Vegas, remember giving a talk a little while ago, had to walk through a casino like 25 times to and from where I was going. And again, I don't say this to be disparaging of the people that are in casinos at seven in the morning, but

I just couldn't imagine, like if you said to me, Peter, we have a job for you, you just have to sit in the casino and play blackjack and we'll pay you a million dollars a month to do this and cover all your losses and you can keep all the winnings. I couldn't do it. I couldn't imagine something less appealing. And yet there are obviously people who can ruin their lives doing this. Why? And by the way, there are things that I'm addicted to that most people would look at and say, who could do that?

This why question, I don't think we have an answer to yet. And yet it totally fascinates me. To me, that's the most interesting question in this space. How does Anna work with clients? She's a psychiatrist. One of the first steps that she thinks about, and I think this is valuable for any of us that are trying to cope with our own addictions, is she does a four-week dopamine fast, which means a four-week total abstinence from the behavior that one is trying to rid themselves of.

She said that 80% of her clients, her patients, will feel better after the four-week fast. Now, she also noted some of those people need medications to help them through that. So, for example, if a person is trying to do a dopamine fast around alcohol, they may actually require benzodiazepines medically to help with that transition. Of course, that's not always the case. She also talked, I think, I can't remember if this was in her book or we talked about it, but I think we also discussed

A woman that was basically smoking pot 24-7 and was doing it because of her anxiety. But of course, turned out she was having all the anxiety because she was smoking all the pot. But this wasn't realized until she was able to sort of abstain from it.

Okay. Another thing that I found just interesting sort of nuance was around pain and pleasure. One of the examples we used was that of cold plunging. So people have heard me talk a lot about cold plunging. I'm a huge fan of it, although I still firmly maintain it has no longevity benefit. There's no zero protective benefit of cold plunging. So to all the biohackers out there, I'm sorry, but I don't think this is going to make you live longer.

But I do think there are two distinct benefits. I think one is a reduction in inflammation and muscle soreness. And I think the other for select people is an improvement in mood. Anna talked about how she's tried cold plunging many times and has never experienced an improvement in mood. And I was like, oh, that's super interesting. I've heard many people say that, but I've heard just as many people share my experience, which is no matter what mood I'm in, no matter how foul it is,

If I get into a 40 degree bathtub, bury myself to my neck for 10 minutes,

I feel insanely good after that. And again, it's not unlike the issue we discussed earlier of why do some people have the key go in the lock for alcohol and it's like both thumbs up, other people don't have it. What it really comes down to is endogenous dopamine production from pain. So Anna talked about how we live in a state of homeostasis. This is obviously a factor in

Spread across all of biology. So when it comes to maintaining regular glucose levels, when it comes to maintaining a regular pH, body temperature, all of the core things that allow us to live require homeostasis and the body has remarkable tools for adjusting up and down to keep us in that window. And dopamine is no exception.

And so, when we do something that is difficult, that induces pain, and the two examples that she gave were cold immersion and exercise, the body has to offset that pain somehow, and it does so by increasing the endogenous production of dopamine.

What's different about this is, one, it's not a huge rush of dopamine that you get for free. It's this dopamine that you kind of had to work for to offset something you're doing that's actually causing pain. So when you remove the painful stimulus, i.e. when you get out of the cold plunger, when you stop the workout, you have this lingering effect of that heightened dopamine. But again, it's a physiologic level and it hasn't been sort of a hijacked level. There was a line in Anna's book that...

She credits to the person who said it, and I can't remember who that was, but I loved it. Our brains are like cactuses that now reside in rainforests. So we evolved in an environment where stimulation was relatively modest and our brains had normal tools.

for coping with the up and down swings of dopamine. And now we live in the most stimulating environment imaginable. And obviously we just didn't have enough time to adapt.

Anybody can sort of follow the logic there. And so I think that makes a lot of sense. And it probably speaks to kind of what I think of as the big takeaways from this. So the big takeaways here, especially if you're a parent, is to sort of ask the question, what are we doing to prevent our kids' brains from being hijacked by this? So even the world you and I grew up in, more than 10 years older than you, but whether you grew up in the 70s or the 80s,

We still grew up in a relatively stimulation-free world. I mean, the most stimulating thing in my life was a cheap cathode ray tube TV watching reruns of Happy Days. Like, that was the pinnacle of stimulation in my life. And today, forget about it. Kids wouldn't even know what that is if they saw it.

So everything is in Technicolor. And two things she said really probably stand out. One is social media. The other is pornography. Again, I think I brought up the example of when I was a kid, pornography was a Playboy magazine. Today, it's VR, literally VR.

All of this stuff, there's just no way around it. As a parent, I think you just have to be the one that's in charge of saying, we're going to absolutely minimize, avoid these things to the best of our ability. I don't think there's much I would add here because so much of this is advice. I think everybody already kind of knows about how much you limit smartphones, social media, all of those things. Those are the big takeaways from this podcast. A few follow-up questions there. First is on the hair ability piece. So about

50 to 60%, which is large. And I know we've talked in other podcasts about the importance of like family history and taking a detailed family history, typically as it relates to diseases, cardiovascular disease, Alzheimer's, things of that nature, cancer.

So when you're having patients and new patients do family histories, are you now having them also include addictions in there? Have you always done that? Yeah, it's a good question. So we don't have dedicated questions around it, but usually we almost always come up with it just through the detailed questioning around everything else. And the reason is it's very difficult for a person to struggle with addictions.

an addiction to alcohol or drugs and not have it creep into their health. So it's very common that we hear, uncle Jimmy, he died of heart disease when he was 60, but truth be told, he had a real drinking problem and da, da, da, da. So yeah, we usually emerge from the family history knowing full well, but I actually think it's a good point. I think we could be more deliberate about it. And we obviously pay just a lot of attention to this when it comes to mental health as well, because when you go through the family history and you see

number of family members with mental illness, you just realize that there's a greater susceptibility as well. Yeah. Let's talk a little bit more about cold therapy. So you do that, you mentioned for you in particular for mood, you said that's not the case for everyone, but there is a good amount of people who get that benefit. And so do you find for yourself that

It's more of a, if you routinely do cold plunges, it's kind of like a consistent benefit. Or do you ever have days where you're like, I'm in a terrible mood. Like I need to just step away from the computer, jump in. Do you kind of use it both ways or how do you think about that? I occasionally do use it as the total reset. And by the way, I don't know that that even needs to be done in the most extreme version of a cold plunge. Like I really think that

Having your face dipped in a bowl of cold water, I've talked about this in the past, can stimulate the mammalian dive reflex. So you have a big enough bowl, you put your head into it, even just covering your face. That can, in theory, I suppose, at least trigger an autonomic response that upregulates the parasympathetic system via the vagus nerve. And that can

tone down the sympathetic system. Actually, this is a great example of coming back to a previous podcast. So the one with Joel Jamison, where we talked about HRV, I think he did a very good job in that podcast explaining that you don't want to think about one system being on, one system being off between parasympathetic and sympathetic. You just really want to think about them always both being on. And it's just a question of the balance. Are you revving one up more than the other? You mentioned that in addition to cold therapy, Anna talked about

Exercise can also be a mood stabilizer for people. Do you see that for you? Yeah, yeah, yeah. I mean, if you deprive me from exercise, it's noticeable within a day. When you work with patients, how do you think, because there's obviously a huge spectrum of this, some of it can be as simple as, I'm just not going to look at my phone an hour before bed. Other can be deep addictions. And so how do you think in your work with patients of

When you're starting to recommend, hey, let's just try these behaviors versus let's go see a specialist to work on this in a more nuanced, detailed manner. I think for the most part, we like to see people try to solve this on their own using neighborhood as the tool. So what do I mean by that? If I'm sitting around holding my phone.

I'm looking at it frequently. There's no two ways about it. And by the way, I can be very good about not looking at social media, but it's also because I don't really like social media. But the truth of it is, if I'm sitting around and my phone is on my lap or it's in my pocket,

I'm going to be checking email. I'm going to be checking texts. I'm going to be reading news quite often. So if I want to avoid that, I have to come up with an alternative. And that's where my bat phone is a good alternative, right? If I'm going somewhere where I need a phone to make phone calls,

but I don't want to have anything to do. I just bring my second phone, my bat phone, which doesn't have email on it. I don't even know the phone number. Nobody knows the phone number, so it never gets a text message. It's basically just a device that makes calls and has podcasts on it if I want to listen to a podcast. So that's something that I'm just going to look at less because I fixed the neighborhood in a sense.

And so I think that's sort of generally what I try to get patients to think about is, yeah, like how do you not have your phone in your room? How do you not have your phone with you for an hour before bed? Not because you're white knuckling it, but because you've come up with another thing in your routine that wouldn't have a phone with you. So if you go and do a sauna cold plunge before bed, it's easy to displace the phone. But if I say, I want you to sit there and stare at the wall, but not have your phone, that's a tougher ask.

You do archery every now and then you go hunting and when you do, it's basically like being off the grid. So you're hiking, you're deep in the woods. It's not like you're kind of sitting around your house. There's no TVs. So during those periods of time, those handful of days, do you find that not being on your phone, not having technology when you come back to the world, do you use it less? Is that kind of like a natural dopamine fast or no? I wouldn't say so because I don't think it's long enough.

I do enjoy that. I just came back from a trip a little while ago where we were bow hunting in a very, very remote area. So there was no wifi, there's no cell service. My phone didn't work once except for the one place where one guy had one of those little Starlink things.

Once or twice a day, you could make a phone call or something. Yeah, everything about that is cool, which you don't have to be hunting to do it. You could just be camping in the right spot. But everything about waking up super, super early, going to bed once the sun goes down, and not being inundated with anything was great. And so...

I don't think that would constitute a fast because at least in my case, it's not nearly long enough, but it's enjoyable nonetheless. It also probably maybe made me feel a bit better in knowing that I guess I don't have an addiction to that at least because I also didn't experience withdrawal. I was like quite happy to not have the device.

Awesome. Let's move on to the next one, which is Fung's podcast, heavily on CRISPR gene editing. Really interesting episode, pretty technical at times, but also it's a topic I feel it's talked about so much. You hear CRISPR, you hear gene editing. We've written about PCSK9 gene editing and how that can have an impact on cardiovascular disease. So do you want to talk about your biggest takeaways, insights you learned from that?

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