The Peter Attia Drive - #304 – NEW: Introducing quarterly podcast summaries - Peter shares his biggest takeaways on muscle protein synthesis, VO2 max, toe strength, gut health, and more

Episode Date: June 3, 2024

View the Show Notes Page for This Episode Become a Member to Receive Exclusive Content Sign Up to Receive Peter’s Weekly Newsletter In this quarterly podcast summary (QPS) episode, Peter introduces a new format aimed at summarizing his biggest takeaways from the last three months of guest interviews on the podcast. Peter shares key insights from each episode, covering diverse topics such as protein and muscle building with Luc van Loon, toe strength with Courtney Conley, VO2 max with Olav Aleksander Bu, liquid biopsies for cancer with Alex Aravanis, gut health and probiotics with Colleen Cutcliffe, and road safety with Mark Rosekind. Additionally, Peter shares any personal behavioral adjustments or modifications to his patient care practices that have arisen from these engaging discussions. If you’re not a subscriber and are listening on a podcast player, you’ll only be able to hear a preview of the AMA. If you’re a subscriber, you can now listen to this full episode on your private RSS feed or our website at the episode #304 show notes page. If you are not a subscriber, you can learn more about the subscriber benefits here. We discuss: How Peter keeps track of his takeaways from each podcast episode [5:15]; Luc van Loon episode: fat utilization, muscle protein synthesis, dietary protein, aging and inactivity, and more [8:45]; Behavioral changes that have come about from the conversation with Luc van Loon [23:45]; Courtney Conley episode: importance of toe strength and the impact of dedicated foot training [26:45]; Olav Aleksander Bu episode: the importance of VO2 max for lifespan, and the practicalities of measuring and improving VO2 max [36:45]; Behavioral changes that have come about from the conversation with Olav [56:00]; Alex Aravanis episode: liquid biopsies for cancer detection [1:01:30]; Colleen Cutcliffe episode: the importance of gut bacteria balance, and the potential therapeutic uses of probiotics, particularly Akkermansia [1:16:45]; Mark Rosekind: the significant issue of road fatalities and injuries, their causes, and practical safety measures to reduce risks [1:27:00]; and More. Connect With Peter on Twitter, Instagram, Facebook and YouTube

Hey everyone, welcome to a sneak peek, ask me anything or AMA episode of the Drive Podcast. I'm your host, Peter Atiya. 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 peteratiamd.com forward slash subscribe. So without further delay, here's today's sneak peek of the Ask Me Anything episode. Welcome to a special AMA episode of The Drive. We know that at times our interviews can be quite technical,

and one of the most common requests we hear is that listeners would love to hear summaries of episodes we've done. As such, we are testing out a new style of AMA for this episode. Before I get to it, I want to sort of explain to you how I interact with my podcast. As you all know, I'm sure we have an amazing team of analysts who help me prepare for each and every episode of The Drive. So I'm typically going into an interview with anywhere from 10 to 20 pages of single spaced notes that have me very familiar with the topic of discussion and lay the groundwork for where we're gonna go. During the interviews, of course, you might not be able to see this

because hopefully the camera is on the guest and not me. I am typically feverishly taking notes because I'm learning as the podcast is going. At the end of every podcast, I typically take the most important things that I have learned and I transcribe them onto five by eight inch cards. Any podcast might have somewhere from one to three or four of these cards filled out. And you can imagine someone doing this back

in the way that you would make a crib sheet in college. Very small writing, but nothing that's on there is wasted. And sometimes there's diagrams, tables, et cetera. Well, it kind of occurred to us that people might want to see what my takeaways are from a podcast. And so in this episode, what we're going to do is look back at the last quarter's podcasts,

and I'm going to share my notes from the podcast. In other words, I'm going to share what I learned personally and what I think were the most important insights. In addition to that, I'm going to comment where applicable if any of these learnings have led to a behavior change in me and or with my patients. In this particular summary AMA, we cover the following podcasts, Luke Van Loon, Courtney Conley, Olaf Alexander Boo, Alex Aravinis, Colleen Cutcliffe, and Mark Roskind. Through these episodes, we speak about topics such as protein, building muscle, VO2 max,

the importance of toe strength and lower leg strength, liquid biopsies and cancer, the gut microbiome and probiotics, and how to mitigate the risks of automotive deaths. I want to be clear. I don't think that this podcast is even remotely a substitute for having listened to those podcasts. In fact, if you were only listening to this, having not listened to that, the information that I spit out will be kind of jarring and might lack some context. So my real hope is that this is viewed as an adjunct to being able to listen to the podcast. Furthermore, it might serve as a reason to go back and listen to a podcast, especially if you haven't listened to it and what I talk about peaks your interest. As this is a new episode style for us, if you like it, and if you find value

in this conversation, please let us know because I think we'd continue it. Obviously, if people don't find this interesting, there's no need for us to do it, and we could go back to regular AMAs. But our intuition is that if this is indeed valuable, a once-quarterly summary might be of value to you as well. 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. And if you're not a subscriber, you can watch the sneak peek of the video on our YouTube page. So without further delay, I hope you enjoy this special episode summary AMA of the drive. Peter, welcome to a special AMA. How you doing? Very well. Thank you. Before we get started, there's a question I've been forgetting to ask you. But now that the McLaren Senna Lego is officially available, how many have you put together? I'm actually really embarrassed to answer that question. I have not put any together,

but I have bought four. So I don't know which of those statements is more ridiculous. You're building the fleet when the time comes. Exactly. I'm creating a generational supply of McLaren MP4 for Legos. And of course, I'll build a few along the way. But the goal is like to have one to build with every child, every grandchild, every random kid that comes to my door when I'm 80 trick or treating. Hey, you wanna come in and build an MP4 for with me?

Like a creepy old man? I love it. Such a specific request for the trick or treaters. I don't have any candy for you, but let me tell you what I got. But I got some Legos. You can also build them with the police who then show up about 30 minutes later. So just keep an extra few in the back. Yeah.

I'm just accumulating them. I love it. So for today's AMA, we're going to do something a little different and it kind of stems from one of the things we hear a lot is we know sometimes our episodes can be technical. And with that, people love to kind of understand not only like summaries of the episodes, but also what you take away from them. And so with that said, do you kind of want to walk people

through how this style came about and how we're thinking about it? Yes. So I appreciate the fact that our podcasts are long and obviously quite deep and that's by design. And I personally don't even have time to go back and listen to most of them, which is a bit of a shame because despite what people might assume, I'm not capable of assimilating everything that comes out of a podcast.

So, you know, in the past year or so, being cognizant of that, I have got into a habit, which is during the podcast itself, I am feverishly taking notes when the guest is speaking. Luckily, I'm able to do this off camera. So you generally don't see that I'm doing that. But that seems to me the best time for me to get the insight out of the episode. What I then do is immediately following the podcast almost always on that day, maybe letting it go one more day, but usually on that day I take out these five by eight cards I have and I then re-synthesize everything from my prep and the notes that I took during the podcast

onto five by eight cards. Here the goal is to really minimize the cards because I want the cards to be the highest yield thing imaginable that six months or six years from now I would go back to and that captures the salient essence of what I learned. In particular, it's always with an eye towards something that I didn't know before or something that maybe I knew but didn't realize how important it was. And obviously, I'm always looking for something that's going to change my mind or change my practice.

Okay. So fast forward to a month ago, we were sitting around with the podcast team and I don't know, I almost just mentioned in passing that I did this. I think you guys decided, well, can you read a couple of your cards to us? I remember we sat there on a call and I just rattled off a bunch of cards and I think your eyes kind of opened up like saucers and you thought, why would we not share this with people? This is valuable. I think that's what got us here. Yeah. And I think for the listener viewer, how we're going to kind of break it up is we'll look at some recent episodes we've done and kind of look at it from two realms. One of what you think

are the most important takeaways, insights, your biggest learnings. And then the second is if you've changed your mind, changed your behavior, how you work with yourself, work with your patients, anything of that nature as well. And so we'll kind of hit those two prongs for each. The last thing I'll say is, I think we're excited about this type of episode because we thought it was really interesting during our conversation, but for listeners and viewers, if you like it

or don't like it, let us know because it's one of those we can always continue to do in the future because we clearly have no shortage of episodes coming up. I would like to reiterate that point. I mean, it's a bit of work to put this together. It seems to me that it's worthwhile. So if folks like this, they should let us know because I could easily see doing this quarterly. And if folks think this is not valuable enough, then I'll keep my notes to myself and I'll still be doing it, because it's valuable to me. Yeah, you can put the notes by the McLaren Legos

you haven't built yet. Perfect, so the first episode we're gonna hit was just an awesome episode with a great guy, Luke Von Loon. So do you wanna walk through, I mean that was an action packed episode on a topic protein, which I know you're very

passionate about. We've talked a lot about, but I think some of the insights that came from there were very interesting. And so I think let's just start with Luke's episode and kind of go through what were some of the biggest insights, takeaways, learnings that you had from that conversation. 2.5 Yeah, again, please don't confuse what I'm about to say with any sort of substitute for listening to the episode. In fact, if you haven't listened to the episode, it will feel very out of context and maybe even jarring for me to just give you my bullet points. I will preface it by saying one thing with respect to Luke's episode, which is this wasn't

the first or even the second or even the third episode we did where we focused very heavily on protein. And yet despite that, the richness of this episode surprised me. So with that said, we talked a lot about something called the fat athletes paradox. And by fat, I mean, fat slash athletes paradox. So there's this idea that when you look at the muscle of an athlete and you look at the muscle of someone with type two diabetes, so you're looking at two opposite ends of the metabolic spectrum, you're going to see large stores of intramyocellular lipids. You're

going to see large stores of lipid within the muscle. I remember hearing this before, but I think what came into focus for me was the idea that this is one of the limitations of static information. Because in the case of the person with type 2 diabetes, that intramuscular lipid store is indeed just that. It is a depot. It is a place where excess energy is seeping out of adipose tissue and remaining stored in the muscle.

In fact, as we saw in our podcast a couple of years ago with Gerald Schumann, that's one of the hallmarks of the cascade of events that leads to insulin resistance. The question is, why aren't athletes not insulin resistant? They're the exact opposite of that. It comes down to the fact that for athletes, that is less a storage depot and more a state of flux. For the athlete, the intramyocellular lipid is indeed a fuel source and it's being turned over rapidly. That's the key takeaway there that's really big.

It's that just because you have triglyceride in the muscle on a biopsy, if you biopsied the muscle of an athlete and of the diabetic, you're going to see high amounts, much higher amounts of fat than you would see in a non-elite athlete, non-diabetic. But it's important to understand one is a constant flux that's being used to prime the pump. The other is obviously a pathologic finding. That's the other point there as well, which is that the reason the athlete has that storage of fat so readily available is it's an immediate access at that low end aerobic

fuel point. So if you can think about zone two, we talk about that a lot. The idea is the minute you jump into that energy system, you want to make sure that you're burning lipid and not burning glucose. So moving on from fat and that athlete's paradox, the next thing I made note of here was the idea that amino acids are signaling molecules in and of themselves. Now, this is relevant because it speaks to the fact that the ingestion of protein by itself stimulates muscle protein synthesis, even in the absence of activity.

So how does this work and why is this relevant? So the amino acid signals mTOR, we understand that. Of course, mTOR is the master nutrient sensing molecule. The activation of mTOR signals muscle protein synthesis even in the absence of activity. Now, when you combine protein intake with exercise, you're going to get more muscle protein synthesis. What I remember and I made note here is Luke made this analogy of it's like the bricks calling the brick layers. I thought that was very clever.

Another point, and this was actually brought up by Lane in one of our first podcasts where Lane talked about sort of the isotope labeling of amino acids to understand the flux of amino acids, talked about how there are about 300 grams of amino acids being utilized per day. Most of this is actually recycled endogenous amino acids. What do I mean by that? If 300 grams of amino acids each day are being utilized, you're not eating 300 grams per day. What's happening?

You might be eating 150 grams per day. That's the exogenous input. The muscle itself is turning over and part of what's being turned over is being reincorporated. So that much I knew. I don't think I knew that it was 300 grams or if I did, I'd forgotten. But this is what was really wild to me was that it takes somewhere between 50 and 100 days for the complete turnover of a muscle. In other words, if I look at a muscle on my body today, I look down at my bicep. It's a little bit interesting to think that a hundred days ago,

it was made up of completely different amino acids. So in other words, in two to three months, you are completely turning over every muscle in your body. Luke mentioned later in the podcast that that turnover is even more rapid in the brain to the tune of about 30 days. Try to let that sit with you in your brain that 30 days ago, a month ago, the actual structure, the proteins that make up your brain were a totally different

set of amino acids. We talked a little bit about the difference between bodybuilders and endurance athletes. Bodybuilders, when they are undergoing muscle protein synthesis, obviously based on the nature of the training stimulus, you're seeing more myofibular protein synthesis in the type two fibers. Whereas endurance athletes, obviously based on the nature of their training stimulus, you're seeing an increase in two things, mitochondrial protein synthesis and capillary density. Again, this is occurring in the type one fiber. So

I'll restate that. Bodybuilders are getting bigger muscles, more contractile force, myofibular protein synthesis. This is occurring in the type two fiber. The athlete is increasing mitochondrial protein synthesis and capillary density in the type one fibers. An editorial comment on top of that, we want both of those things to occur. Both of those things should be the desired outcome and therefore that's why we want both types of training. Another very interesting discussion

we had was on the idea of what drives muscle protein synthesis. So he listed four things, and I think this is a very helpful guide as you start to think about protein choices you're making. So the first is what is the digestibility of the protein? So here we make a big contrast between plant protein and animal protein. This is where animal protein has an enormous advantage over plant protein, and that it is far more digestible. Now, there are things that you can do about that. We've talked about this, right? So if you want to eat or get the majority of your protein from plants, that's fine, but you will need to accommodate that by, for example, cooking it, making sure it's cooked, and or eating sources that have higher amounts of certain amino acids, which I'll get to in a second.

The second is the rate of digestion. Not just the digestibility, but now what's the rate of digestion? Here, let's take perhaps the most potent type of protein, which would be say beef protein or something like that, there's a significant difference between ground beef and steak. So the rate of digestibility is obviously greater for ground beef than steak. Similarly, whey versus casein. They're both milk proteins, but whey has a much higher rate of digestibility than casein. Again, here's where you'd see cooked versus raw. Amino acid composition is now the third factor here.

An example would be collagen versus whey. Whey has a much higher quality amino acid composition than collagen. Collagen tends to be rich in a handful of amino acids. If my memory serves me correctly, I think it's glycine and proline. Whey of course has a more distributed wealth of amino acids. Then of course the fourth and final component here is what's the total amount of protein that's being consumed. The more protein that's being consumed, the more muscle protein synthesis. Quick primer on the milk proteins. We did talk about this, right? So milk protein is about 80% casein and 20% whey. So whey, much more rapid casein, much slower digestion profile. Both are valuable.

We spoke about this. There was a study that Luke was a part of. I think we've written a newsletter on it talking about how much, much larger doses of protein could contribute to muscle protein synthesis in a study that was using casein because of this long lag in which it was dragged out. He mentioned that plant protein is specifically low in lysine and methionine. And so if you're going to eat plant protein, you're going to have to probably look for ways to supplement those if you want to maximize muscle protein synthesis. Okay.

We have more notes from this podcast. This is a bit longer than normal, truthfully, but again, there was so much here. A very powerful image in my mind from this podcast was the idea that when you look at the graphs that describe loss of muscle in the elderly, everybody's familiar with what these graphs look like, which is they start out here and they drop down here.

And for those listening to me, it's kind of like a smooth curve that drops like a stone, usually once people are in the eighth decade of life in their mid-70s. And he made such a fantastic point, which is if you look at this at the population level, which is always how the data are presented, it appears to be a physiologic

phenomenon. What does he mean by that? A physiologic phenomenon is an inevitability. It's physiologic. You're going to lose muscle as you age, and it occurs on this nice, beautiful, smooth curve. And he said, but if you actually look at it at the individual level, that's not at all what it looks like.

It's actually a graded step function. So again, if you're watching me, this is easier to see. It's here's your muscle mass and then boom, a big drop. And then you stay there for a little while and then boom, a big drop and away you go and away you go. And he said, what it really comes down to the individual level is a series of discrete periods of inactivity that result in sudden, relatively speaking, meaning over a period of months or weeks, big drops in muscle mass that are never recovered. And I'll tell you, it's been a while since that episode. I think about that every minute of every day, and I'm only in my fifties. And I keep thinking, what do I need to do to make sure I don't experience one

of these two week or two month episodes that's going to result in an irreversible loss of muscle mass? And again, it really comes down to how do you not get injured? And even if you don't have an injury, how do you make sure you're staying active? Well, this gets to another important thing we discussed, which is the idea of anabolic resistance. Again, this has come up over and over on various podcasts that I've done on this topic. Basically, we talked about the two drivers of this, which are aging and inactivity. It's crystal clear that inactivity and age drive this. So the question is, is it one or the other? Is one simply a proxy for the other, et cetera? He offered great ideas for why maybe both of these

things play a role. So let's start with inactivity. This is the easier one to test because you can actually do an experiment. So you could take young people who ordinarily would not experience anabolic resistance and you can render them inactive. And there's very elegant experiments done where you take young people and you put one leg in a cast for a period of time. And the experiment he talked about was one week. So this is beautiful because each person is their own control. So young person, one leg in a cast, one leg not.

And just in one week, there was a 35% difference between the active and inactive leg in a young person with respect to muscle protein synthesis and therefore anabolic resistance. Again, that very compellingly says inactivity plays a huge role. But that doesn't mean that aging inherently doesn't also account for some of this. There are lots of hypotheses that he put forward. Is there a decrease in amino acid uptake, a decrease in gut absorption, a decrease in the circulation of amino acids, something called splenknick sequestration going up? Basically losing amino acids to the splenknick system in the GI tract, reduction of perfusion.

Of course, that's true elsewhere in the body, so maybe it's true here, and lower muscle uptake. Finally, lower mTOR signaling. It certainly is listed as one of the hallmarks of aging that nutrient sensing goes down. Boy, I've got even one more set of notes here, but I'm going to just go for it because I think it is pretty important. I made a table while we were talking about the difference between myofibrillar muscle protein synthesis and muscle contractile tissue protein synthesis in response to the following stimuli, exercise, dairy protein, so whey and casein, and collagen protein, which again,

you may recall a second ago, I said, look, collagen protein is not a complete protein. It's mostly just got a couple of amino acids in it. And when you look at exercise, you see that it gives a huge increase in both myofibrillar muscle protein synthesis and muscle contractile tissue. When you look at dairy protein, you get a big increase in myofibrillar muscle protein synthesis and muscle contractile tissue. When you look at dairy protein, you get a big increase in myofibrillar, but not in contractile.

I think that's not surprising. When you look at collagen protein, it's relatively small on both. What this highlighted for me and the reason I made these notes was total protein quality plays a big role in myofibrillar protein synthesis, and exercise plays the biggest role in generating contractile tissue protein synthesis. So at the risk of maybe doing a bit more, but I apologize, I probably took more notes on that podcast than most others. Those were the salient points that I took away from the podcast with Luke. You hinted at a few things there in terms of like behavior changes or what you're Those were the salient points that I took away from the podcast with Luke.

You hinted at a few things there in terms of like behavior changes or what you're thinking about. One of which is just consistently thinking about the importance of always training and not taking time off, whether that's by choice, meaning you're going on a trip or life gets in the way and you decide not to train or by not choice, which is like an injury and you're not able to train. So if you think about any behavior changes that you've made in either your training, protein consumption, how you look at that throughout the day since that episode, what's

jumped out to you? Yeah. A few things you've already mentioned a couple. Another one is for really long endurance activity, which I still do some of, maintaining dietary fat matters in that pathway that we talked about at the outset where you want to maintain intra myocellular lipids. So again, not an issue for me personally because I've never ever been a low fat diet guy, but it's worth keeping in mind for athletes out there who tend to be lower on their fat

consumption, you are depriving yourself of a pump prime. Obviously, we talked a lot about the need for activity. I guess the two other things I'd say before we leave this are, I have been using time restricted feeding a little bit more lately in myself, but I'm always making sure to get protein while I'm in that non-feeding window. Because again, I don't believe there's a particular magic to not eating for 18 hours a day. It's just a tool to calorically restrict. And so I don't care if I get another couple hundred calories of protein during that window.

I guess the final point here was really from my wife who is really adamant about her collagen protein drink in the morning. I think I feel a little more comfortable telling her, hey, there's nothing wrong with drinking your collagen protein. If you happen to really love that formulation or whatever, knock yourself out. It's also not a very complete protein. Maybe at a minimum supplement it with something else. But clearly consuming a collagen protein

is not a superior protein. I think that is definitively true. One last piece on Luke before we move on is there was one quote he said, which I thought was just really, really good and succinct, and I'll read it and then it's, you know, we can talk about it, which is he said, I've had a lot of people in my life asking me

how important is it whether I take my protein shake before or after the training session, but I never had someone come up to me and say, look, how important is it if I skip one training session or miss one training session? Consistent training is the benefit, consistent training so that every meal is a greater impact on your muscle protein synthesis.

And I thought that was really good because we see a lot of questions come through and sometimes people may overthink potentially protein and when to take it and when not to. But for him to say, whether you consume before or after, the biggest thing is just always be training, always be consistent and never take time off. I thought was a really good point for people to kind of remember.

Yep, yep. All right, let's move on to the podcast with Courtney Conley. Thank you for listening to today's sneak peek AMA episode of The Drive. If you're interested in hearing the complete version of this AMA, you'll want to become a premium member. It's extremely important to me to provide all of this content without relying on paid ads. To do this, our work is made entirely possible by our members, and in return, we offer exclusive member-only content and benefits above and beyond what is

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