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    Improve your decision-making, frameworks for learning, backcasting, and more | Annie Duke (#60 rebroadcast)

    enSeptember 02, 2024
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    Podcast Summary

    • Decision Making, Backcasting, PokerBackcasting and evaluating decisions using a decision matrix are effective strategies for making informed decisions, especially when information is incomplete, as learned from the experiences of poker champion Annie Duke.

      This podcast episode, featuring an interview with decision strategist and World Series of Poker Champion Annie Duke, offers valuable insights into decision-making, particularly in situations where information is incomplete. The conversation delves into the importance of backcasting and evaluating decisions using a decision matrix. Annie shares her experiences and lessons learned from her career in poker, which she believes is an excellent model for making decisions in real life. The episode, first aired in 2019, remains relevant and offers actionable information that can be applied to everyday decision-making and behaviors. The Drive podcast, which focuses on translating the science of longevity into accessible content, is supported by its members, who receive exclusive benefits and content.

    • Decision making in complex fieldsDecision making in complex fields is more like poker than chess due to incomplete information and luck. Recognizing this can help us make informed decisions.

      Decision-making, especially in complex fields like medicine, is not like playing chess with perfect knowledge. Instead, it's more akin to poker, where incomplete information and the influence of luck are significant factors. Even with complete information, uncertainty about the outcome remains. This is because the world is stochastic, and small differences in initial conditions can lead to vastly different outcomes. Humans may not be naturally wired to understand probability theory, which adds to the challenge of making informed decisions. However, recognizing the role of incomplete information and luck in decision-making can help us approach situations more thoughtfully and effectively.

    • Probabilistic ThinkingEffective decision-making requires recognizing and accounting for uncertainty, a skill not naturally wired in us. Superforecasting game and personal experiences with poker highlight the importance of probabilistic thinking and correcting errors in our thinking.

      Our ability to think probabilistically is crucial for effective decision-making, yet it's not a skill we're naturally wired for. The speaker shared an experience of participating in an exercise involving answering 20 questions with quantifiable answers, requiring the estimation of a range that likely contains the correct answer. This exercise, known as the "superforecasting" game, highlights the importance of probabilistic thinking and reveals how many of us underestimate the uncertainty of the world. The speaker also mentioned their personal experience with playing poker, which led them to develop an interest in probability and statistics. They emphasized the significance of recognizing and correcting errors in our thinking, as most of us tend to overestimate our certainty and underestimate the role of chance. By becoming more aware of our biases and learning to think probabilistically, we can improve our decision-making and adapt to the inherently uncertain nature of life.

    • Poker and personal growthPoker's unpredictability and variable reinforcement schedule fuel motivation and focus, leading to personal growth and cognitive skill development.

      The game of poker provides a unique environment for personal growth and the development of cognitive skills due to its elements of hidden information, uncertainty, and variable reinforcement. This was exemplified by the story of a young man named Steve, who started playing poker in the 1980s and eventually became a successful player by learning from his losses, finding mentors, and adapting to the game's unpredictability. Poker's inherent uncertainty leaves room for players to rationalize their losses and inflate their winnings, creating a strong motivation to continue playing and improving. The variable reinforcement schedule, where wins come at unpredictable intervals, further fuels this motivation and leads to a high level of engagement and focus. This environment, as described in the conversation, is reminiscent of the concept of "centers of excellence" where individuals from various backgrounds come together and learn from each other, ultimately leading to the emergence of world-class talent. Additionally, the conversation touched upon the difference between fixed and variable reinforcement schedules and how the unpredictability of poker, as a variable reinforcement schedule, leads to specific behaviors in players, such as a heightened focus and engagement. Overall, the story of Steve's journey into poker highlights the unique benefits of the game and the role it plays in fostering personal growth and cognitive development.

    • Variable reward systems and compulsive behaviorThe unpredictability of rewards in variable reward systems can lead to compulsive behavior, as the human brain focuses on the most recent reward or lack thereof, rather than the overall average reward

      The unpredictability of rewards in variable reward systems can lead to compulsive behavior, even when the overall average reward is known. This is because the human (or animal) brain doesn't easily grasp the concept of an average, and instead focuses on the most recent reward or lack thereof. This is why slot machines and variable ratio reinforcement schedules are so effective at keeping people (or rats) engaged, even when they're losing more than they're winning. In poker, this effect is amplified because the rewards are not only variable but also dependent on both luck and skill. The person playing poker may feel "due" for a win, even when the statistical evidence suggests otherwise, leading to continued play despite losses. This is why it's important to adopt a long-term perspective and understand the underlying probability distributions in these types of systems. Skill plays a role in the long run, but in the short term, luck can have a significant impact on outcomes.

    • Skill vs Luck in GamesThe influence of skill and luck varies greatly depending on the specific context of a game or situation. In games like poker, the skill gap is relatively narrow, and luck can heavily influence the outcome. However, in games where the skill gap is vast, such as professional sports, the influence of luck is minimal.

      The distinction between skill games and luck games can be blurred, especially when the skill gap is narrowed. While games like baseball or poker have elements of both, the outcome can often come down to the last possession or play, which can be influenced by luck. However, when comparing teams or individuals with vastly different skill levels, such as a professional NFL team versus a Little League team, the influence of luck is minimal. It's essential to understand that the skill gap and the presence of luck can vary greatly depending on the specific context. In games like poker, the skill gap is relatively narrow, and once you've learned the basics, the outcome can be heavily influenced by luck. Texas Hold'em, a popular variant of poker, is an example of a game where the goal is to make the best five-card hand out of seven or nine possible cards. The ranking of hands is clear, with hands like straight flushes being the rarest and highest-ranking hands. However, the presence of community cards in Texas Hold'em introduces an element of luck, as players must use some of the same cards. Other variants of poker, like in the movie "The Cincinnati Kid," where each player is dealt their unique five cards, have less luck involved since players do not share any cards. Ultimately, it's crucial to recognize that both skill and luck play a role in various games and situations, and the balance between the two can shift depending on the context.

    • Texas Hold'em community cardsThe community cards in Texas Hold'em provide valuable information for probabilistic calculations and behavioral analysis, shaping betting strategies and determining hand strengths.

      In Texas Hold'em poker, the community cards in the middle of the table provide important information about each player's possible holdings, allowing for probabilistic calculations and behavioral analysis. This information helps determine the relative strength of each player's hand and informs betting strategies. Newcomers to the game may initially have an advantage due to being unpredictable, but this advantage is often short-lived as experienced players learn to range them effectively. Understanding the implications of the community cards and observing player behavior are key skills in Texas Hold'em poker.

    • Quitting fast in pokerQuitting fast in poker, or knowing when to fold, helps minimize losses and move on to better opportunities. In poker, a good player wins roughly 56% of the time, but the excitement and risk of no limit poker can lead to greater volatility and asymmetric outcomes.

      In poker, players are encouraged to quit when they have a negative expectation, allowing them to minimize losses and move on to other opportunities. This concept, known as "quitting fast," is a key strategy in poker and helps mitigate the pain of losses due to loss aversion. Poker also comes in two styles: limit and no limit. In limit poker, a good player wins approximately 56% of the time, meaning the opponent wins 44%. This frequent reinforcement keeps players engaged and motivated to continue playing. Conversely, in no limit poker, players experience greater volatility and asymmetric outcomes, making the game more exciting but also riskier. Overall, the unique dynamics of poker, particularly the ability to quit when the odds are against you, make it an intriguing game that combines strategy, risk, and reward.

    • Expected Value beyond MoneyPeople value more than just money in poker and a negative expected value doesn't necessarily mean a player is having a bad experience. Entertainment and learning can add value to the game.

      While the concept of expected value in poker is often thought of solely in terms of money, it's important to remember that people value other things beyond just the monetary aspect. When players come into the game with a negative expected value, they may still be experiencing positive value overall due to the entertainment and learning experiences they gain. This concept was particularly prevalent in the poker scene of the 1990s, where players focused on creating a fun and valuable experience for everyone involved. A famous example is the late poker player Chip Reese, who made a fortune in poker and backgammon but was also known for his ability to make everyone around him happy, leading them to want to play with him despite potentially losing money. This symbiotic relationship shows that poker is not truly zero-sum, as the value people gain from the game goes beyond just the money exchanged.

    • Poker, mathematics and learningMathematics plays a crucial role in poker, and continuous learning and adaptability are essential for mastering the game. Good decisions don't always lead to good outcomes, and evaluating decisions requires considering potential outcomes, probabilities, and consequences.

      Poker, like any complex skill, offers endless opportunities for learning and improvement. The speaker, a professional poker player, shared his personal journey from a casual player in Montana to a dedicated professional in Las Vegas. He emphasized that the enjoyment of the game comes from different things for different people, and his unique understanding of the game's mathematics set him apart from his opponents early on. However, he acknowledged that there's always more to learn and that the game's complexity can be both a challenge and a source of fascination. Another important insight he shared was the realization that good decisions don't always lead to good outcomes, and bad decisions don't always lead to bad outcomes. This understanding challenged the simplistic notion that success or failure is solely determined by the quality of the decision. Instead, he encouraged a more nuanced approach to evaluating decisions, taking into account the potential outcomes, their probabilities, and the consequences of each outcome. In essence, the speaker's experience highlights the intricacies of poker and the importance of continuous learning and adaptability in mastering the game.

    • Transparency in Decision MakingTransparency in decision-making leads to greater accountability and learning from outcomes, reducing the likelihood of attributing poor results to the decision itself.

      People tend to judge the quality of decisions differently based on the transparency of the situation. When the outcome is unexpected or the decision-making process is opaque, individuals are more likely to attribute the poor result to uncertainty rather than the decision itself. However, when the decision-making process is transparent, individuals are more likely to accept the outcome, regardless of whether it was good or bad. This phenomenon, known as "resulting," can be observed in various domains, including football, business, and personal life. It's essential to recognize this bias and strive for greater transparency in decision-making processes to improve accountability and learning from outcomes. Ultimately, understanding the role of transparency in decision-making can help individuals and organizations make better decisions and learn from their mistakes.

    • Decision outcomesBoth good and bad decision outcomes offer valuable learning opportunities. Avoiding bad outcomes shouldn't prevent taking risks and innovating.

      The pain and learning experienced from making a decision with a good outcome versus a bad outcome can vary greatly depending on the situation. While making a bad decision with a good outcome may seem less painful, it can still lead to valuable learning opportunities. However, the focus on avoiding bad outcomes and the fear of being labeled as an "idiot" can lead decision-makers to play it safe and avoid innovation or taking risks. This can ultimately hinder progress and growth. It's important for individuals and organizations to recognize the value in learning from all types of decisions and outcomes, and to strive for a balanced approach to decision-making. The fear of bad outcomes should not overshadow the potential benefits of making bold, innovative decisions.

    • Risk assessment in marketAccurately assessing risk, not just return, is crucial for efficient resource allocation in markets. Underestimating or overestimating volatility can lead to significant consequences.

      Efficient resource allocation in any market requires accurate assessment of risk, not just return on capital. A model that underestimates or overestimates volatility can lead to significant consequences for the amount of capital deployed. The concept of "Rock versus Ray Rock" highlights the importance of understanding the true risk-adjusted return on capital. When unexpected events occur, it's crucial to explore potential reasons, including the possibility that one could have done better or worse. In decision-making, it's essential to think critically and consider all possible directions, including up, down, and orthogonal, to avoid building false consensus or making decisions based on data to support a narrative rather than finding the truth. People's reluctance to acknowledge mistakes and their tendency to move slowly or default to inaction can hinder innovation and effective decision-making. The willingness to take calculated risks and make decisions confidently, like Pete Carroll in sports, can lead to success.

    • Transparency and unusual decisionsPeople's reactions to unusual decisions depend on their perception of transparency. Proven successful leaders face less criticism for their unusual decisions. It's crucial to examine good outcomes and consider alternative paths for learning.

      People's reactions to unusual decisions depend on their perception of transparency. When leaders make decisions that are not immediately understood, they may face criticism. However, as Belichick's career shows, once leaders have proven their success, fans and critics become more tolerant of their unusual decisions. It's essential to encourage exploration of both good and bad outcomes, especially the unexpectedly good ones, as they hold valuable lessons. The Y2K example illustrates that good outcomes can result from good decisions, from inevitable outcomes, or from a combination of both. However, it's only by examining the counterfactuals that we can truly understand the impact of our decisions. By focusing on the "morbidity conference" in our heads, we miss opportunities to learn from our good outcomes and consider alternative paths. To be effective decision-makers, we must balance our focus on the outcomes we didn't like with an exploration of the ones we did. This approach will help us become more thoughtful and intentional in our decision-making.

    • Counterfactual AnalysisConsidering counterfactuals, or possibilities of what could have happened, can lead to better decision-making and improved performance by identifying factors contributing to success or failure and making adjustments accordingly.

      Focusing only on negative outcomes and avoiding unexpected events can limit learning opportunities and reinforce risk aversion. Instead, it's essential to consider counterfactuals, or the possibilities of what could have happened, and evaluate preferences and probabilities for each outcome. This approach, inspired by the analysis of historical events like the D-Day invasion, can lead to better decision-making and improved performance in various domains, including archery or poker. By considering all possible outcomes and their likelihood, individuals can identify the factors contributing to success or failure and make adjustments accordingly. This iterative process of exploration and evaluation can ultimately lead to greater progress and elite performance.

    • Skillful reflectionExamining wins and losses through skill leads to continuous improvement and mastery, requiring a higher level of thinking and introspection.

      Examining both wins and losses through the lens of skill, not just focusing on losses, is crucial for improvement and growth. This concept can be applied to various skills and experiences, including poker and learning to swim. The framework for learning involves becoming consciously incompetent, consciously competent, and eventually unconsciously competent. However, it's essential to acknowledge that examining wins and losses through skill requires a higher level of thinking, which can be challenging as it may challenge our beliefs and identity. This process may lead us to question our decisions and outcomes, potentially turning a win into a loss. But ultimately, this level of introspection is necessary for continuous improvement and mastery.

    • Self-deception in industries with significant luckIn industries with clear outcomes, significant luck, tight feedback loops, and high stakes, individuals have a greater capacity for self-deception. Analyzing past decisions and learning from them is crucial for long-term success.

      In industries where outcomes are clear and the influence of luck is significant, individuals have a greater capacity for self-deception. This is particularly true when there's a strong short-term influence of luck, a tight feedback loop, and significant skin in the game. Poker and high-frequency trading are examples of such industries. The capacity for self-deception can lead to either abject failure or improvement, and it's unclear whether individuals naturally tend to think this way or if it's a result of their experiences. However, there are individuals across various industries who are naturally inclined to analyze their decisions and outcomes to improve their performance. The ability to critically evaluate past decisions and learn from them is essential for long-term success in these industries.

    • Long-term decision makingLonger time horizons require critical thinking, self-reflection, challenging assumptions, and a systematic approach to decision-making to minimize biases and their consequences.

      As the time horizon for making decisions increases, the importance of critical thinking, self-reflection, and challenging assumptions becomes more crucial. This is because with longer time horizons, there is more leeway to let biases influence decisions without immediate consequences. This is in contrast to activities like trading options, where feedback is quick and consequences are more significant. Therefore, it's essential to adopt a systematic approach to decision-making, model the world counterfactually, and encourage challenge and innovation. The longer the time horizon, the more important it is to dig deep into potential problems and propagate a culture of learning and improvement within teams. This is why activities like swimming, which require a longer time horizon to master, demand a higher level of thinking and introspection.

    • Backcasting goalsConsidering our goals from the finish line perspective can provide insights, help make better decisions, and create a more robust strategic plan by identifying practical steps and considering potential challenges and opportunities.

      Thinking about our goals from the perspective of the finish line, or backcasting, can provide valuable insights and help us make better decisions. By asking ourselves what we want to be able to do when we're older, we can identify the practical and pragmatic steps we need to take now to achieve those goals. This approach also allows us to consider the role of luck and how we can decrease the chances of negative events occurring. By working backwards, we can create a more robust strategic plan that takes into account potential challenges and opportunities. The Centenarian Olympics concept is an example of this, encouraging us to think about what we want to be able to do at 100 and working backwards to determine what we need to be able to do at each stage of life to make that a reality. This approach can help us live more intentionally and make decisions that align with our long-term goals.

    • Decision making and luckEffective decision-making requires recognizing the role of luck and skill, embracing the probabilistic nature of decisions, and identifying the curves in our decision-making process to navigate them effectively.

      Understanding the role of luck and skill in our lives is crucial for effective decision-making. Malbrough's book "The Success Equation" is recommended for further exploration of this topic. Additionally, embracing the probabilistic nature of decisions and recognizing when to go fast and when to slow can help us make better decisions and avoid analysis paralysis. The framework discussed allows us to identify the curves in our decision-making process and navigate them more effectively, ultimately freeing us up to make faster decisions in the straightaways and even on the curves. This conversation highlighted the importance of deep exploration and the value of a comprehensive understanding of complex concepts. The Drive podcast offers exclusive member benefits, including detailed show notes, Ask Me Anything episodes, a premium newsletter, access to a private podcast feed, and a highlight reel of previous episodes, for those seeking to delve deeper into these topics.

    • Podcast disclaimersAlways consult a healthcare professional for medical advice, podcasts don't form doctor-patient relationships, and be aware of potential conflicts of interest.

      Dr. Peter Attia's podcast provides valuable information on various health and wellness topics, but it's important to remember that the information shared is for general informational purposes only. No doctor-patient relationship is formed through the podcast, and users should not rely on it as a substitute for professional medical advice. Additionally, users should be aware of any potential conflicts of interest and disclosures made by Dr. Attia, which can be found on his website. To access member-only benefits, learn more, and engage with Dr. Attia, users can visit peteratiamd.com, find him on social media platforms, or leave a review on their preferred podcast player. Remember, always consult with a healthcare professional for any medical concerns.

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    In this “Ask Me Anything” (AMA) episode, Peter dives into two important health topics: uric acid and protein, examining them from unique perspectives. For uric acid, he explores its metabolic role and connection to various diseases, focusing on the potential causal link with cardiovascular disease. He also discusses factors influencing uric acid levels, such as diet, genetics, and lifestyle, providing practical tips for effective management. Shifting to protein, Peter delves into its role in appetite and weight management, the consequences of insufficient protein, and the “protein leverage hypothesis” linking protein deficiency to obesity. He covers optimal protein intake and its impact on energy expenditure, and he compares the satiety effects of solid versus liquid protein. Finally, Peter shares his strategy for incorporating protein into a comprehensive weight management plan.

    If you’re not a subscriber and are listening on a podcast player, you’ll only be able to hear a preview of the AMA. If you’re a subscriber, you can now listen to this full episode on your private RSS feed or our website at the AMA #62 show notes page. If you are not a subscriber, you can learn more about the subscriber benefits here.

    We discuss:

    • Overview of episode topics (and an important discussion on fanny packs) [2:00];
    • Understanding uric acid: its role in metabolic processes, its association with gout and kidney stones, its impact on blood pressure, and more [6:00];
    • Non-modifiable factors that influence uric acid levels [11:00];
    • Modifiable factors that influence uric acid levels [14:15];
    • Association between high uric acid levels and cardiovascular disease [20:00];
    • Evidence suggesting a causal link between high uric acid levels and cardiovascular disease [24:00];
    • Inconclusive evidence about the cardiovascular benefits of lowering uric acid pharmacologically [28:15];
    • Exploring the potential risks of low uric acid levels in neurodegenerative diseases [37:00];
    • Managing uric acid levels: dietary interventions and pharmacological approaches [42:00];
    • The impact of protein on appetite and weight management [44:00];
    • The consequences of insufficient protein on eating behaviors and satiety [52:15];
    • The relationship between protein deficiency and obesity: exploring the “protein leverage hypothesis” [57:15];
    • The impact of protein intake on energy expenditure [1:02:15];
    • Determining optimal protein intake to avoid deficiency and support health [1:05:45];
    • The role of different amino acids and protein sources in promoting satiety [1:08:15];
    • Comparing the satiety effects of solid vs. liquid protein sources [1:10:30];
    • Peter’s framework for incorporating protein intake into a strategy for controlling body weight [1:12:00]; and
    • More.

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    The Peter Attia Drive
    enAugust 12, 2024

    #312 - A masterclass in lactate: Its critical role as metabolic fuel, implications for diseases, and therapeutic potential from cancer to brain health and beyond | George A. Brooks, Ph.D.

    #312 - A masterclass in lactate: Its critical role as metabolic fuel, implications for diseases, and therapeutic potential from cancer to brain health and beyond | George A. Brooks, Ph.D.

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    George A. Brooks is a renowned professor of integrative biology at UC Berkeley. Known for his groundbreaking "lactate shuttle" theory proposed in the 1980s, George revolutionized our understanding of lactate as a crucial fuel source rather than just a byproduct of exercise. In this episode, George clarifies common misconceptions between lactate and lactic acid, delves into historical perspectives, and explains how lactate serves as a fuel for the brain and muscles. He explores the metabolic differences in exceptional athletes and how training impacts lactate flux and utilization. Furthermore, George reveals the significance of lactate in type 2 diabetes, cancer, and brain injuries, highlighting its therapeutic potential. This in-depth conversation discusses everything from the fundamentals of metabolism to the latest research on lactate's role in gene expression and therapeutic applications.

    We discuss:

    • Our historical understanding of lactate and muscle metabolism: early misconceptions and key discoveries [3:30];
    • Fundamentals of metabolism: how glucose is metabolized to produce ATP and fuel our bodies [16:15];
    • The critical role of lactate in energy production within muscles [24:00];
    • Lactate as a preferred fuel during high-energy demands: impact on fat oxidation, implications for type 2 diabetes, and more [30:45];
    • How the infusion of lactate could aid recovery from traumatic brain injuries (TBI) [43:00];
    • The effects of exercise-induced lactate [49:30];
    • Metabolic differences between highly-trained athletes and insulin-resistant individuals [52:00];
    • How training enhances lactate utilization and facilitates lactate shuttling between fast-twitch and slow-twitch muscle fibers [58:45];
    • The growing recognition of lactate and monocarboxylate transporters (MCT) [1:06:00];
    • The intricate pathways of lactate metabolism: isotope tracer studies, how exceptional athletes are able to utilize more lactate, and more [1:09:00];
    • The role of lactate in cancer [1:23:15];
    • The role of lactate in the pathophysiology of various diseases, and how exercise could mitigate lactate's carcinogenic effects and support brain health [1:29:45];
    • George’s current research interests involving lactate [1:37:00];
    • Questions that remain about lactate: role in gene expression, therapeutic potential, difference between endogenous and exogenous lactate, and more [1:50:45]; and
    • More.

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    The Peter Attia Drive
    enAugust 05, 2024

    #311 ‒ Longevity 101: a foundational guide to Peter's frameworks for longevity, and understanding CVD, cancer, neurodegenerative disease, nutrition, exercise, sleep, and more

    #311 ‒ Longevity 101: a foundational guide to Peter's frameworks for longevity, and understanding CVD, cancer, neurodegenerative disease, nutrition, exercise, sleep, and more

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    In this special episode, Peter provides a comprehensive introduction to longevity, perfect for newcomers or those looking to refresh their knowledge. He lays out the foundational concepts of lifespan, healthspan, and the marginal decade. Additionally, Peter discusses the four main causes of death and their prevention, as well as detailing the five key strategies in his longevity toolkit to improve lifespan and healthspan. Detailed show notes provide links for deeper exploration of these topics, making it an ideal starting point for anyone interested in understanding and improving their longevity.

    We discuss:

    • Key points about starting exercise as an older adult [2:45];
    • Overview of episode topics and structure [1:45];
    • How Peter defines longevity [3:45];
    • Why healthspan is a crucial component of longevity [11:15];
    • The evolution of medicine from medicine 1.0 to 2.0, and the emergence of medicine 3.0 [15:30];
    • Overview of atherosclerotic diseases: the 3 pathways of ASCVD, preventative measures, and the impact of metabolic health [26:00];
    • Cancer: genetic and environmental factors, treatment options, and the importance of early and aggressive screening [33:15];
    • Neurodegenerative diseases: causes, prevention, and the role of genetics and metabolic health [39:30];
    • The spectrum of metabolic diseases [43:15];
    • Why it’s never too late to start thinking about longevity [44:15];
    • The 5 components of the longevity toolkit [46:30];
    • Peter’s framework for exercise—The Centenarian Decathlon [47:45];
    • Peter’s nutritional framework: energy balance, protein intake, and more [58:45];
    • Sleep: the vital role of sleep in longevity, and how to improve sleep habits [1:08:30];
    • Drugs and supplements: Peter’s framework for thinking about drugs and supplements as tools for enhancing longevity [1:13:30];
    • Why emotional health is a key component of longevity [1:17:00];
    • Advice for newcomers on where to start on their longevity journey [1:19:30]; and
    • More.

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    The Peter Attia Drive
    enJuly 29, 2024

    #310 - The relationship between testosterone and prostate cancer, testosterone replacement therapy, and tools for predicting cancer aggressiveness and guiding therapy | Ted Schaeffer, M.D., Ph.D.

    #310 - The relationship between testosterone and prostate cancer, testosterone replacement therapy, and tools for predicting cancer aggressiveness and guiding therapy | Ted Schaeffer, M.D., Ph.D.

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    Ted Schaeffer is an internationally recognized urologist specializing in prostate cancer and a returning guest on The Drive. In this episode, Ted provides insights into the role testosterone plays, or doesn't play, in the initiation and progression of prostate cancer. He unpacks the findings and limitations of the recent TRAVERSE trial, exploring the complex relationship between testosterone and prostate cancer. Ted delves into the molecular nature of prostate cancer, explaining the androgen receptor saturation theory and the potential impact of testosterone on cancer growth. He also discusses the use of the Decipher test to predict cancer aggressiveness and guide targeted treatment. Furthermore, Ted shares how he counsels patients regarding testosterone replacement therapy (TRT), including its safe administration in patients with low-grade prostate cancer. Additionally, he highlights advancements in prostate cancer therapies and biomarkers that help develop precise treatment strategies while minimizing the need for broad androgen deprivation therapy.

    We discuss:

    • Background on the TRAVERSE trial: insights into exogenous testosterone and prostate cancer risk [3:00];
    • The androgen receptor saturation theory: how different organs respond to varying levels of testosterone [10:30];
    • The relationship between testosterone levels and prostate cancer aggressiveness: how aggressive prostate tumors have lower androgen receptor activity and rely on different growth mechanisms [16:15];
    • Using the Decipher score to assess prostate cancer aggressiveness and guide personalized treatment strategies [23:45];
    • Considerations for testosterone replacement therapy: how Ted counsels patients, how TRT can be safely administered in patients with low-grade prostate cancer, and more [31:15];
    • Advancements in prostate cancer therapies and PSA as a biomarker for precise treatment decisions, minimizing the need for broad androgen deprivation therapy [38:30]; and
    • More.

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    The Peter Attia Drive
    enJuly 22, 2024

    #309 ‒ AI in medicine: its potential to revolutionize disease prediction, diagnosis, and outcomes, causes for concern in medicine and beyond, and more | Isaac Kohane, M.D., Ph.D.

    #309 ‒ AI in medicine: its potential to revolutionize disease prediction, diagnosis, and outcomes, causes for concern in medicine and beyond, and more | Isaac Kohane, M.D., Ph.D.

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    Isaac "Zak" Kohane, a pioneering physician-scientist and chair of the Department of Biomedical Informatics at Harvard Medical School, has authored numerous papers and influential books on artificial intelligence (AI), including The AI Revolution in Medicine: GPT-4 and Beyond. In this episode, Zak explores the evolution of AI, from its early iterations to the current third generation, illuminating how it is transforming medicine today and unlocking astonishing possibilities for the future. He shares insights from his unconventional journey and early interactions with GPT-4, highlighting significant AI advancements in image-based medical specialties, early disease diagnosis, and the potential for autonomous robotic surgery. He also delves into the ethical concerns and regulatory challenges of AI, its potential to augment clinicians, and the broader implications of AI achieving human-like creativity and expertise.

    We discuss:

    • Zak’s unconventional journey to becoming a pioneering physician-scientist, and his early interactions with GPT-4 [2:15];
    • The evolution of AI from the earliest versions to today’s neural networks, and the shifting definitions of intelligence over time [8:00];
    • How vast data sets, advanced neural networks, and powerful GPU technology have driven AI from its early limitations to achieving remarkable successes in medicine and other fields [19:00];
    • An AI breakthrough in medicine: the ability to accurately recognize retinopathy [29:00];
    • Third generation AI: how improvements in natural language processing significantly advanced AI capabilities [32:00];
    • AI concerns and regulation: misuse by individuals, military applications, displacement of jobs, and potential existential concerns [37:30];
    • How AI is enhancing image-based medical specialties like radiology [49:15];
    • The use of AI by patients and doctors [55:45];
    • The potential for AI to augment clinicians and address physician shortages [1:02:45];
    • The potential for AI to revolutionize early diagnosis and prediction of diseases: Alzheimer’s disease, CVD, autism, and more [1:08:00];
    • The future of AI in healthcare: integration of patient data, improved diagnostics, and the challenges of data accessibility and regulatory compliance [1:17:00];
    • The future of autonomous robotic surgery [1:25:00];
    • AI and the future of mental health care [1:31:30];
    • How AI may transform and disrupt the medical industry: new business models and potential resistance from established medical institutions [1:34:45];
    • Potential positive and negative impacts of AI outside of medicine over the next decade [1:38:30];
    • The implications of AI achieving a level of creativity and expertise comparable to exceptional human talents [1:42:00];
    • Digital immortality and legacy: the potential to emulate an individual's personality and responses and the ethical questions surrounding it [1:45:45];
    • Parting thoughts [1:50:15]; and
    • More.

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    The Peter Attia Drive
    enJuly 15, 2024

    Zone 2 training: impact on longevity and mitochondrial function, how to dose frequency and duration, and more | Iñigo San-Millán, Ph.D. (#201 rebroadcast)

    Zone 2 training: impact on longevity and mitochondrial function, how to dose frequency and duration, and more | Iñigo San-Millán, Ph.D. (#201 rebroadcast)

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    Iñigo San-Millán is an internationally renowned applied physiologist and a previous guest on The Drive. His research and clinical work focuses on exercise-related metabolism, metabolic health, diabetes, cancer metabolism, nutrition, sports performance, and critical care. In this episode, Iñigo describes how his work with Tour de France winner Tadej Pogačar has provided insights into the amazing potential of elite athletes from a performance and metabolic perspective. He speaks specifically about lactate levels, fat oxidation, how carbohydrates in food can affect our lactate and how equal lactate outputs between an athlete and a metabolically unhealthy individual can mean different things. Next, he discusses how Zone 2 training boosts mitochondrial function and impacts longevity. He explains the different metrics for assessing one’s Zone 2 threshold and describes the optimal dose, frequency, duration, and type of exercise for Zone 2. Additionally, he offers his thoughts on how to incorporate high intensity training (Zone 5) to optimize health, as well as the potential of metformin and NAD to boost mitochondrial health. Finally, he discusses insights he’s gathered from studying the mitochondria of long COVID patients in the ICU.

    We discuss:

    • The amazing potential of cyclist Tadej Pogačar [2:00];
    • Metrics for assessing athletic performance in cyclists and how that impacts race strategy [7:30];
    • The impact of performance-enhancing drugs and the potential for transparency into athletes’ data during competition [16:15];
    • Tadej Pogačar’s race strategy and mindset at the Tour de France [23:15];
    • Defining Zone 2, fat oxidation, and how they are measured [26:00];
    • Using fat and carbohydrate utilization to calculate the mitochondrial function and metabolic flexibility [35:00];
    • Lactate levels and fat oxidation as it relates to Zone 2 exercise [39:15];
    • How moderately active individuals should train to improve metabolic function and maximize mitochondrial performance [51:00];
    • Bioenergetics of the cell and what is different in elite athletes [56:30];
    • How the level of carbohydrate in the diet and ketogenic diets affects fuel utilization and power output during exercise [1:07:45];
    • Glutamine as a source for making glycogen—insights from studying the altered metabolism of ICU patients [1:14:15];
    • How exercise mobilizes glucose transporters—an important factor in diabetic patients [1:20:15];
    • Metrics for finding Zone 2 threshold—lactate, heart rate, and more [1:24:00];
    • Optimal Zone 2 training: dose, frequency, duration, and type of exercise [1:40:30];
    • How to incorporate high intensity training (Zone 5) to increase VO2 max and optimize fitness [1:50:30];
    • Compounding benefits of Zone 2 exercise and how we can improve metabolic health into old age [2:01:00];
    • The effects of metformin, NAD, and supplements on mitochondrial function [2:04:30];
    • The role of lactate and exercise in cancer [2:12:45];
    • How assessing metabolic parameters in long COVID patients provides insights into this disease [2:18:30];
    • The advantages of using cellular surrogates of metabolism instead of VO2 max for prescribing exercise [2:25:00];
    • Metabolomics reveals how cellular metabolism is altered in sedentary individuals [2:33:00];
    • Cellular changes in the metabolism of people with diabetes and metabolic syndrome [2:38:30]; and
    • More.

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    The Peter Attia Drive
    enJuly 08, 2024