#285 - AMA #55: Exercise: longevity-focused training, goal setting, improving deficiencies, managing emotional stress, and more
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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. So

Welcome to Ask Me Anything, episode number 55. I'm once again joined by my colleague, Nick Stenson.

Given that it is now officially the new year, today's AMA is focused all around exercise. This is a topic we speak about a lot, and it's not only because of how important it is, but also because of how many questions we see come through from our audience around it. And the majority of these questions revolve, in one way or another, around how someone can improve their cardiorespiratory fitness, increase their muscle mass, increase their strength, or all of the above.

As such, in today's AMA, we cover the importance of having a goal in your training and why, for myself and a lot of my patients, it's training for the centenarian decathlon that provides the structure. How can we help identify the pillars of exercise where people are most efficient? And from there, how can people use periodization training to not only make the most improvements in those areas, but also create some variety in training?

Through this, we look at case studies of different phenotypes and what a typical workout might look like for different types of people. For example, those who come to exercise with a strong background in one area but not in another.

people who show up without any exercise training at all. We then focus on how stress can impact training. And by that, I mean emotional stress. And this is something I think we can all relate to that we go through periods of our life when we're under great emotional stress. And the question is, how should that factor into the decisions we make around training? If you're a subscriber and 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 AMA number 55. Peter, welcome to another AMA. How are you doing? Very well.

I think we're going to get right into it because we got kind of a big one today. So with it being the new year, we know a lot of people are going to start to either take their exercise more seriously, start to exercise, thinking of switching up their exercise routines. And we see so many questions around exercise come through. We thought this would be a good time to make it kind of an all exercise AMA.

And some of the questions we see from people are, they're wondering how to improve their cardiorespiratory fitness, how to increase their muscle mass, their strength, oftentimes how to do both.

And so we pulled questions that are going to look at how you solve these problems with clients in your practice. And this includes first really identifying and clearly defining what the goal of training is, because as you often talk about, if you don't clearly identify the goal, you don't really know what to do.

And then from there, helping people understand how they can identify the area in their life that they need the most help in when it comes to exercise. And then we'll start to get into more technical questions on how people can use periodization training, how they can make improvements in areas that are most needed. And we're even going to look at some case studies of what a different weekly workout could look like for a few different types of people.

From there, we're then going to step back and also look at some training questions that apply to everyone, no matter what level of expertise they're at. This includes how stress can impact a workout and also how people should look at wearables and the data from wearables as it relates to making decisions on training. So we got a lot. So with all that said, anything you want to add before we get into it? No, I like your ambition, man. We'll see what we can do.

I think we first need to start a reminder for people on how you look at training and the goal of training. Because for you, you're not training to run a marathon, be a power lifter. Instead, you're training for something else. And you've talked about this before, but I think it is important.

to just kind of lay that foundation for people so they know why you're making the recommendations, why you're doing what you're doing. So do you want to remind people quickly what the centenary in decathlon is and why you use that as your training goal?

Yeah. As you said a second ago, I am no longer an athlete. I don't train for anything specifically. In fact, very recently, you know how your phone will pop up pictures of something that occurred like this time five years ago or whatever? Well, it popped up a picture of me from 2014 and it was after a training session. This is back when I lived in San Diego. You remember where Fiesta Island is, Nick?

Oh yeah. Awesome. So Fiesta Island is where we used to train for the time trials. And it was a picture of me and Meb after a training session. So Meb was running, I was riding. I look at the picture there, I'm in my kit arm around Meb and it's like, he probably weighs 138 pounds. I weigh like 168 pounds, 25 pounds or whatever less than I am today. And

There's just no comparison to what I was then versus what I am today. I trained three times more than I train today in volume. And it was very specific. And I've talked about this, but again, I think it's worth reiterating.

When I stopped competing, when I was done with cycling, done with swimming, done with being competitive at some level, I needed to find another goal because of what you said in the intro, which is it's very difficult to train without a purpose.

I talk about this in the book, but I really had an epiphany in the summer of 2018. So I kind of had an aimless three years where I was exercising and I was reasonably fit. There was no purpose. It wasn't anchored to anything. This all came in a flash of inspiration as I was sitting at the funeral of the parent of a close friend of mine.

realizing that in the last decade of this person's life who had died, they were largely debilitated physically. And that was tragic to me because I had seen them be healthy in their 60s and 70s. So that's what gave me this idea of we need a goal and we need to treat life just as we would treat an athletic event. And this idea of a centenarian decathlon is

came to my mind in part because decathletes are generally regarded as the best overall athletes, despite not being the best in any one of the 10 things that they do. Now, of course, centenarian decathlon is not an actual event. Maybe some people will do decathlons when they're centenarians, but even becoming a centenarian is not necessarily the objective. We don't have that much control over how we stretch our genes. That said, I

What I imagine is in the last decade of my life, what do I want to be able to do and how do I begin to train for that now? And when you take that look at the future and you say, look, these are the things I want to be able to do, you can apply metrics to those activities. You can say, hey, if I want to be able to hike on uneven surfaces to the tune of two mile round trip in an hour,

That requires this much cardiorespiratory fitness, this much strength, this much balance. And I know how much each of those things will decline over the next decades. So how much stronger do I need to be at 50 than I would expect to be at 85 or 90? There's a figure I pulled here. If you could pull it up, Nick, I think it's a bit of a messy figure and the message is very clear.

Perfect. This is a figure that shows on the left, it shows women, and on the right, it shows men. The bottom two figures show physical activity level over time. So age is always shown on the x-axis. And the upper figure shows fat-free mass in kilograms on the y-axis versus, again, age on the x-axis.

Fat-free mass, of course, is a very good proxy for lean mass or muscle mass. You can see that these have data collected all the way from when people are teenagers up until the end of life.

And again, you don't really have to be a statistician to see the remarkable trends here. So there's some obvious differences between men and women. The most notable one of just the difference in lean mass, men have significantly more lean mass than women. But if you put that aside, you'll realize two things. The first is that we have a steady increase in muscle mass and lean mass, both for men and women that occurs from birth right up until about the age of 25.

And then you have a relatively minor decline in lean mass from 25 to 75. But then what happens at 75, Nick? Yeah, it's off a cliff. It literally falls off a cliff.

Now we do the same exercise for physical activity. Exercise, no pun intended, meaning you do the same visual exercise. You watch that from the ages of 25 to 75, physical activity level is even more consistent and conserved than lean mass in both men and women. And yet what happens at the age of 75 for both men and women?

Yeah, same thing. It just falls off a cliff. Now, of course, this figure cannot give us causality. I can't look at this figure and tell you that the reason physical activity level falls off a cliff at 75 is because muscle mass does the same, nor can I tell you that muscle mass is declining because physical activity goes down. But it's hard for me to imagine that what's happening here is not causality.

In other words, I suspect that what's happening is that at 75 or thereabouts for the average person, activity declines. And as activity declines, muscle mass declines. And as muscle mass declines, activity declines further. And these things spiral out of control.

And remember, the average life expectancy is about 80. So that means that for people who are living to average life expectancy and slightly beyond, they're basically going to spend the last five to 10 years of their life in a very poor physical state. And if there's anything that I hope people take away from the stuff that we've been talking about, it's that you must focus on healthspan at least as much as you focus on lifespan.

And if there's an enormous failure in medicine 2.0, it's the myopic focus on lifespan at the complete exclusion of healthspan.

With that rant sort of over, therein lies the why. It really doesn't matter what your athletic background is. Maybe you were a stud athlete growing up. Maybe you've never played a sport in your life and you've never done so much as run a local 5K. Doesn't matter. Everyone needs to be an athlete for life and therefore everyone needs to think about becoming the best version of their centenarian decathlete.

Remind me, what was the furthest you've ever swam? Furthest in one shot I've ever swam is about 28 miles.

So looking back at that picture of you and Meb, would you say you were the better athlete and had more athletic achievements than Meb? Or do you think it's not quite that clear? Meb having won the Boston marathon, having won the New York marathon, probably the most decorated American marathoner. I'm going to give the slight nod to Meb on that. You did bike around Fiesta Island a lot though. So

So you have that going for you. I was probably a better swimmer than Meb. Maybe I can take that. I'm sure if you put Meb on a bike, he would have ridden circles around me. Oh, yeah. Dude's just a machine. So with that said, I think then we also need to quickly remind people of what you call the four pillars of exercise, which is...

If you agree that this is what you're going to train for, which is ultimately life and life as you age and being able to do what you want to do. And sometimes people I think can get lost in the very specifics of like, okay, I need to be able to do exactly this or exactly this. But even stepping back for most people, just acknowledging if I'm going to focus on when I'm 80, 90, I want to be able to move freely.

take care of myself. Just the large things that can sometimes give people the goal they need. And so with that said, do you want to quickly remind people on what those four pillars of exercise are that anyone who has that goal is going to need to have all four? Yeah.

I just want to make sure people understand for the centenarian decathlon, we're really thinking about things that are activities of daily living and activities of leisure and pleasure and sport and beyond activities of daily living. So we kind of encourage people in our practice to go through this exercise and make sure they have both of those in there. Now, to your point, I think broadly speaking, the way...

Internally, we talk about this as four pillars, and this is the way I wrote about it in the book. So it's two cardio pillars and two strengthy pillars. Cardio pillars are zone two efficiency. So this is aerobic efficiency or maximum aerobic efficiency, and then peak aerobic output. So that's measured by VO2 max, whereas aerobic efficiency is measured by zone two output. And then on the other side, we have strength.

And within strength, there's a lot. So we'll go into some more detail about what that means because strength involves both muscle quality and motor control and you have eccentric strength and you have concentric strength and all those things. And then you have this other idea that wraps around strength called stability. And of course, stability speaks about the safety with which you can apply that strength, i.e. exert force on the outside world.

and the safety with which the outside world can exert force on you. And of course, inherent with instability are other issues that we think about, especially things that decline as we age, such as mobility, balance, flexibility. Looking deeper into those four, what are people able to track and kind of identify further to know where they're at?

you know, in strength, there's different aspects of it. Maybe just touch on what those aspects are so people know how they can start to measure in their own life where they're at and where they need help. There are so many. So let's take strength as an example. Within strength, we want to think about peak strength. So

So that would be kind of maximum strength. Again, to be clear, that would be what is your maximum one rep max for something. We would want to think about muscular endurance. So the ability to move something that's much lighter, but for many, many reps. It's important to point out, by the way, that you don't have to train at a one rep max to increase your strength.

And you don't have to actually measure at that level. In other words, you could see how much you could do something for five reps, and that would allow you to impute or estimate what you could do for one rep. And if you're a powerlifter who's competing in a sport where you have to do that, of course, that would be insufficient.

For those of us that are not powerlifters, knowing what we could do for our best five reps is a good enough proxy for then calculating what our one rep max would look like. We then talk about various things like motor control. So again, I think this is sort of a hybrid of the strength stability piece, but I gave the example of hiking over an uneven surface. I just got back from 100%.

a hunting trip a little while ago and you're walking around in the dark carrying heavy stuff on obviously uneven surfaces and that's a much more complicated and dynamic situation than riding a stationary bike for example. So we want to be able to train in both of those ranges. You want to be able to train on

under perfect conditions, such as using a machine or being on a bike or something like that. And then you also want to be able to train on variable surfaces and in situations where you have less control. And again, when we talked about cardiorespiratory fitness, lots of things that we measure here. But again, thinking of these in the two extremes, which is what is the maximum output you can sustain with

while still exclusively utilizing your aerobic system. So therefore you're not at all accumulating lactate. And again, I'm being a little bit sloppy in my terminology there, and we can maybe clear that up a bit later, but basically,

What's the maximum output you can sustain without accumulating net lactate? And at the other end of that spectrum, what is the maximum utilization you have of oxygen, which corresponds, of course, not to your maximum output, but more importantly, your maximum aerobic output. Again, these are very quantifiable. And as you know, these are numbers that we know for all of our patients. And I think they're numbers that everybody should know for themselves.

Yeah, and I think that's a great lead into the next place, which is you have the cardio respiratory side, you have the strength side. A lot of people are going to be wondering, okay, how do I know where exactly I'm at in each of those so I can help identify if one or the other needs help or if they both need help? Maybe walk through how people can understand their current state as it relates to those two things.

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