You mentioned, you know, the hamburger that you eat today is not the hamburger you had 50 years ago. Why is that? In a word, it's scale and economics. The truth of it is agriculture is broken. The standard American diet that we have is nothing more than a solution to a business problem. Crop subsidies led to basically the total destruction of soil in the United States. And if nutrient density goes down,
You have to eat more of something. All of this is probably not the end of the world if we didn't consume it in excess. Peter, it's great to finally have you on the show, man. Last time we were here, you very kindly gave us a couple of copies of your book. And I was not someone who actually paid too much attention to my health prior to that. I was just kind of naturally thin. And so I was like, you know, I'm...
healthy um and then on the plane back i started reading the book and i couldn't put it down and by the time we landed i'd finished the book uh and then started actually looking into a lot of the stuff that you're talking about which is all about how to be healthy in a world in which medicine hasn't caught up to many other things that are going on. So talk to us about that, first of all. You have this concept of medicine 2.0 and 3.0, which is really interesting.
well first off thanks for having me guys i'm as you know because we've talked about it over many meals i mean i'm just such a huge fan of your podcast i enjoy it um on all topics so it's an honor to be here and talk about my pet topic um so uh yeah so medicine 2.0 i think to understand it you sort of have to understand a little bit of what medicine 1.0 was. So this is basically an evolution of how we think about medicine. And for most of human history, you know, dating back thousands of years.
um there was no scientific basis for medicine so so we didn't without a scientific method you can't really practice the process of science and therefore Anything that was imputed about illness was really thought to be based on the gods or bad humors or things of that nature. So when a person was ill, you didn't really know what to attribute it to, right?
So medicine 1.0 sort of evolved into medicine 2.0 in the latter part of the 19th century. Again, it wasn't just at the advent of the scientific method, which came along 300 years earlier, but it was really other tools that...
enabled it. And one of the most important was the light microscope. So the moment we as a species could appreciate microscopic entities bacteria namely um and and also eventually come to understand that there were things like viruses it it created a whole new infrastructure in the way we thought and the way we treated disease and then when you add to that the uh the advent of antimicrobial therapy and antibiotics
really medicine changed. And it sounds like overnight, because in the grand timescale of human civilization, it was almost an overnight change. And it produced an almost overnight, although in reality, four or five generations, doubling of human life. So we went from basically living to a life expectancy of the late 30s and early 40s to now late 70s, early 80s. And that's largely been due to kind of the amelioration of the following.
We are much better at treating trauma. We are much better at infant mortality. and maternal mortality and we are much better at treating acute conditions primarily those that involve infections so it's largely been those three things that have doubled human lifespan and so medicine 2.0 is humming along and it is the
It's the thing that we're swimming in, right? That's the water of medicine today. And again, it's very good. We collectively wouldn't be sitting here without Medicine 2.0. What I argue in the book is that... Unlike where Medicine 2.0 completely displaced Medicine 1.0, we don't need a Medicine 3.0 to displace 2.0. We want to preserve all the benefits of 2.0. But what we need to do is sort of allocate...
of the portfolio to this thing called Medicine 3.0, which is slightly different. Instead of trying to apply the hammer of treat something when it arrives, which is the Medicine 2.0 strategy, that doesn't seem to work with chronic disease. and it's now chronic diseases that are killing most people in the developed world. We instead have to prevent these things decades before they show up. So you don't treat heart disease when a person has coronary plaque.
Right. That's a process that's been going on for 50 years. Sorry, Peter, to stop you there, because there's going to be a lot of people listening to this who don't know what coronary plaque is. So can you just explain it to them and then move on? Sure. So if somebody has a heart attack...
Why is that, right? So cardiovascular disease is the leading cause of death globally. 19 million people per year die from cardiovascular disease. Number two by comparison is cancer at 13 million. So cardiovascular disease occurs. when plaque accumulates in the arteries of the heart. And the heart is very sensitive to anything that reduces its blood flow and subsequent oxygen. delivery. And so these plaques
accumulate very, very slowly on the order of decades, not years. And we know that these plaques are accumulating in teenagers. And we know this because when you look at cases of young men and women who die in trauma. for reasons that have no relation to heart disease, you still see on autopsy small amounts of coronary plaque accumulating.
And so the idea that we should wait until those coronary plaques become significant enough that either A, somebody has their first heart attack, or B, you do a study on them, like a CT scan of the heart, where you can visibly see the coronary plaque. then we decide to treat them, which would kind of be part of the way that most people would think about this, probably doesn't make sense, right? When instead, you might want to be treating that decades before it shows up. In other words...
using that as an example, you want to treat the causal agents of the disease and not wait for the disease to take hold. So an example of where Medicine 2.0 does this very well is with smoking, right? So with smoking... There's nobody out there saying,
we should get people to stop smoking once they start to develop nodules in their lung that look suspicious for cancer. We don't say that. Why? Because we know that smoking is causally related to lung cancer. And when you know that... you tell people to never smoke and the minute they start smoking you get them to stop regardless of risk and meaning regardless of age or any other risk factor. Similarly, we know what the causal drivers are of cardiovascular disease, right? So it's...
The technical term is hyperbeta lipoproteinemia. That's just a very fancy way of saying the types of cholesterol-carrying molecules that have a certain thing on them called ApoB. So that's the LDL, the VLDL, the IDL, LP little a. All of those little particles are causally related. High blood pressure is causally related. Insulin resistance is causally related. So what we want to be able to do is treat those things.
second they emerge, even if a person is young, otherwise healthy, or otherwise low risk. Another... Very important tenet of Medicine 3.0 is not just the early and aggressive primordial prevention, but it's also this emphasis on health span as being equal to lifespan. Lifespan, I think, is a pretty obvious concept. It's how long you live. And it's quite binary, which makes it easier to understand you're alive or you're dead. Healthspan is a little more subjective.
What one person deems exceptional health span might not be that of another. But regardless, I think people intuitively understand what quality of life means. And it has a sort of physical, cognitive, emotional component. And Medicine 3.0 would treat... the optimization of that at the same level. It's equally important to how long you live. And that's important because what gets measured gets managed, right? And so Medicine 2.0 really optimizes around lifespan.
And therefore, that's the metric that we track. Well, that was really the thing that shook me kind of awake when I was reading the book, because you have this, I think it's a graph and also an explanation to basically. show, this may be overstating it slightly, but the way we currently manage health is essentially we live, then we get sick, and then medicine comes in and extends as much as possible the period of our life when we are sick.
so that we can live longer. But you're living longer while really actually having some real issues, right? And what you were talking about in the book, very powerfully, is how do you extend the period of life when you're not sick? So that you kind of have a very short period of the end of your life when you are maybe dealing with issues and then you die. So you're kind of extending your actual high quality life. And that seems to me like a pretty good thing to be doing.
I think that's honestly what anybody who puts a lot of thought into it will come to the conclusion. And I say that because I spend time with lots of people. where I'm asking them to really make trade-offs and thought around that, right? So I'm sort of saying like, what do you want the last decade of your life to look like?
Like really put some thought into this. Like this is an exercise that we do. It's called the marginal decade exercise because we refer to that last decade of life as the marginal decade.
what i can tell you is i have yet to meet an individual now maybe my sample size is you know only you know hundreds instead of millions but i have yet to meet a person who when contemplating their marginal decade i.e. the last decade of their life, something all of us will have as sure as God made little green apples, everybody is focused far more on what they will be able to do in that decade.
than how old they will be now obviously nobody would view a marginal decade from the ages of 51 to 61 as ideal in other words anybody would argue that hey to die at 61 would be premature and awful we don't want that So we have to take the steps to address lifespan, which means delaying the onset of chronic disease. But I don't see anybody saying that 85 to 95 at very good health is...
is demonstrably worse than 100 to 110 at marginal health, even though you live 15 years longer, something to that effect. So I think- Quality of life is actually what most people really focus on when you force them to kind of go through the exercise of what will it tangibly look like in the end of your life? Do you want to be able to sit on the floor? do you want to be able to stand up how much do you want to be able to ambulate
What does travel mean to you? What does living alone mean? And by living alone, I don't mean necessarily without others, but living without assistance. Do you want to be able to live with your spouse? Or if you are living alone, do you want to be able to care for yourself? um these are things that when people are asked to stop and reflect on them become far more important than the how many years am i going to be
It's a really profound point. And one of the things that I found very interesting in your book, Peter, is when you were talking about type 2 diabetes and how we're not... actually talking about what a serious condition this is. And then I started looking at the stats about obesity and over and the proportion of people that are overweight in this country something like 74% of Americans are overweight I think it's something like 40% of Americans are obese around 10% are severely obese
I mean, that's terrifying. Yeah. I mean, I think there's so many different ways to look at it. And obviously, we need to caveat all of that by saying that... There is this now new class of drugs that more than any other drugs in the history of as long as we've been dealing with this problem appear to be more efficacious.
and with fewer side effects than anything we've seen. So if we bracket that for a moment and say, let's come back to it, the obvious question is, why is this epidemic happening? And what is the... implication of it from the health of the population and economically and what would one need to do to address it so we could go we could talk about any of those that you like yeah but um I think what's causing it would be a good start. Yeah let's do what's causing it actually.
If you could tell the story, because I found it incredibly powerful about the story about when you were working as a surgeon. I think it's the technical term, it's a surgeon's assistant. And you were talking and you were... interacting with the patient just before they went to have a surgery and they told you they weren't an alcoholic.
Yeah. So I was in my, and I go, we have a different system here than probably some of the nomenclature in the UK. So I was an intern at that point in time. So I was, it was the first year of my surgical residencies. I mean, it's the first year I was an actual doctor. So you'd finished medical. school, you've chosen your specialty. And yes, for that, in that particular case, I was doing what was called pre-opping. So getting a patient ready for surgery. This was a gentleman who, um,
needed part of his colon removed because he had colon cancer. And so there's just a checklist of questions you ask these patients, any patient, before they undergo surgery. And one of the questions is about how much alcohol they drink. And the reason for that is not to be judgmental. It's because it really matters in terms of both the anesthesia they receive and also how you manage potential withdrawal from alcohol following surgery.
when they can't actually eat or drink anything by mouth for a few days. So in a manner of normal discussion, this gentleman mentioned that he barely drank alcohol at all, thought nothing of it. And the next day when we are operating on him, and of course, because I was only the intern, I'm not doing any actual operating. I'm retracting. So my job is to hold him open while the chief resident and the attending surgeon are operating. And sure enough, his liver...
was malted with fat. Now that's something you only saw historically in people who were severe drinkers. At the time it was... very poor, this is 25, yeah, almost 25 years ago, it was very poorly acknowledged. that there was a condition called non-alcoholic fatty liver disease, right? Where you had the same appearing liver, but it wasn't occurring because of excess alcohol. It was...
excess calories that were being shunted into that very unfavorable storage location. Now today we recognize this as an epidemic actually, and today this is the leading indication for liver transplantation. in the united states um and you know that's kind of a remarkable statistic when you stop to think about it that there are people who are literally receiving liver transplants today
because their livers have become so cirrhotic due to the scarring and inflammation associated with excess accumulation of fat. And again, that's both from alcohol, but also a significant portion of that is not from alcohol. And when we say not from alcohol... What do we mean? Well, the best of our belief system is this is really caloric excess.
So this is people who are not consuming alcohol. And if they are, they're consuming it minimally. But this accumulation of fat in the liver, along with its concomitant metabolic derangement, is the result of excess calories.
being taken on relative to the level of exertion of an individual. And is that why Americans and Westerners more broadly, because it's a big problem in the UK as well, are so overweight is it that we just eat more than we burn off or is there something else going on in terms of the food system and all the rest of it well i think it's all connected so the you know you have to think about it through the lens of like what's the proximate
ideologic explanation of what's happening. And then you can peel back the layers of, well, why is that happening and why is that happening? So at the simplest level of physics, it's clearly a caloric imbalance. Now that's not the most helpful explanation, right? That's sort of like saying, we're sitting in a room with 20 people. Why are there 20 people? Well, the physics answer is...
20 more people entered this room than left the room. Thank you. That's very helpful. Why? Is there free food being given out? Is there an interesting person in the room that they're all coming to listen to? That's the sort of the real why that we want to get at. So the real why as to why are people consuming more calories than they expend today relative to any time in the past has to do with, I believe, so many factors. And unfortunately, I think.
it's very tempting and i've been i've done this myself so i can i can take responsibility for this in some way it's very tempting to isolate one factor and say it's because there is more processed food it's because we eat too much sugar it's because of social media that keeps us glued to our phones instead of being active. It's because we are not sleeping as well. And the truth of it is, it's a bit of everything. There's no doubt that food is today more hyper palatable.
and more calorically dense than at any time in the past. This is an undeniable fact over the past two decades. It is also absolutely clear that people are on average less. active today than they were 50 years ago. It is also a fact today that people
generally consume lower quality food. Even the same type of thing that they might have consumed, like whether it was a hamburger that you ate 50 years ago or a hamburger today, it's not just that the portion size is larger today, it's that the actual quality. of the food is lower. Now, we don't necessarily know what the impact of each of these things is individually.
But it's very hard to deny that something in the way we eat is probably playing the most dominant role. Can I just ask this question? Because when you were telling that story about the patient's incredibly fatty liver... You mentioned that the guy was drinking a lot of fizzy drinks, soda. And it made me think, number one, that's a huge problem. But number two...
It's something that I noticed here and Constantine's mentioned it as well. Sugar seems to be in everything here. Yeah, like even coming over from the UK where people are hardly all slim and healthy. it's like you get a coffee it it feels like it's got way more sugar in it than than than the exact if you go to a starbucks basically what i'm saying and get a latte
that tastes way sweeter than a latte in the UK. Yeah. Well, that's interesting because in theory, the latte shouldn't be much different. If it's a true latte, it's literally like, are you putting milk in it or half and half cream or whatever? But no doubt when you... go to Starbucks just to pick on Starbucks for the moment. It is unbelievable the amount of calories and sugar.
that are flowing out of their Frappuccinos and all of their drinks I can't even name. And I do find that remarkably interesting. I also think there's probably... I say this probably, like... not definitively there's probably something to be said for drinking calories in excess it being even a little more damning than eating calories in excess. And I think there's decent evidence for that when it comes to sugar. In other words, if a person is going to eat...
50 grams of sugar versus drink 50 grams of sugar. I think there's in the animals very compelling evidence that the latter is more problematic. The reason for it gets into a bit of technical biochemistry but sugar is half fructose and half glucose. Fructose is what gives sugar its sweetness. It's also a molecule that has a very unique metabolism.
Both of them are metabolized quite readily by cells, but the speed at which fructose is metabolized is much higher. And in the process of metabolizing fructose, cells have to... use the currency of energy called ATP. So the rate of ATP depletion in cells within the gut and ultimately the liver as they metabolize fructose.
requires that more energy is put into the system. What does that mean in English? It means that if you're drinking a lot of sugar, even though you're getting energy and you should be satiated, it can actually have the reverse effect, which is... I need more energy. It signals to the brain, I need more energy because there's a depletion of ATP required to increase the speed of metabolism of it relative to glucose, right? So this would be the difference between eating 100 calories.
that is half fructose, half glucose, versus eating 100 calories of glucose. Yeah, that makes sense. And you were talking about the decline in the quality of food. This has been a big part. By the time this video's gone out, the election's already happened, and America's over, whichever side wins. Right, just a...
We're having this discussion not knowing who's going to win the election. Right, right, right. But it has been made into a conversation, which I think is a good thing, that the quality of food in America... has declined over time. And you mentioned the hamburger that you eat today is not the hamburger you had 50 years ago. Why is that? In a word, it's scale and economics, right? So we have to understand, and I...
I think it's very tempting to just demonize Big Food. And to be clear, I don't have a dog in this fight. I don't know anybody that works for Big Food. I don't own Monsanto stock. I truly... think about this from purely a scientific and policy perspective. But what I don't think people understand is the complexity that has been involved in the agricultural revolution and what it takes to feed. billions of people. So the way I think about it is there's a problem statement.
right? The problem statement is, so we can go back in time 100 years, and I'm going to anoint you to the food czars of the universe. Well, we're already fucked then. I say to you, listen, guys, here's the problem you have to solve.
I want you to figure out a way to feed eight at the time, whatever it was, you know, 4 billion people or whatever the number would have been. It would have been less than that. But I want you to figure out a way to feed billions of people. But here's the thing. So one, you have to do that scale.
It's never been done before, right? It used to be you had farmers that would sort of farm locally and they would sort of feed a certain area and that would be the end of it, right? So you have to be able to, if you build to feed a lot of people. You have to be able to transport food and keep it from spoiling when you do. We have to make it taste good. We have to make it really cheap. Go. It's hard to imagine.
that people would come up with a very different system from the one we have today. So what I've referred to, and I'm sure I took this term from somebody else, because there's no way I was the person that came up with this, but what I've referred to is the default food environment. The standard American diet that we have is nothing more than a solution to a business problem. Now, a lot of times...
the solution to a business problem ends up having collateral damage. So if you were a tobacco farmer and I said to you, what are you going to do with all this crop you have?
And you came up with this idea. Well, what if we roll these things up and give them to people and let them light it and smoke it? I mean, it seems to produce great qualities. Have you noticed when people smoke that thing that I have on my field, they don't eat as much, they lose weight, their mental alertness goes up and they feel better?
That's great. So you had a business problem. You had to get rid of that crop. You got rid of that crop. You made this thing. Well, it turned out there was a nasty side effect of that that didn't show up for 20 years, which is sort of killing people as well.
Does that mean that people set out to do that to kill people? Of course not. You never want to kill your customer. It doesn't justify anything in tobacco. It just makes the point that people apply morality to these things when in reality what's really happening is these are just... people trying to solve a business problem, and there are unintended consequences. There are non-linearities everywhere. So the truth of it is agriculture is broken.
I think there's ample evidence to suggest, and this really goes back 100 years, right? So if you go back to the Dust Bowl, which was 90 years ago in the middle of this country, was really when agriculture took a turn for the worse. So call it the 1920s into the... 1930s when crop subsidies led to basically the total destruction of soil in the United States, right? So instead of saying, hey, we'll grow wheat this year.
We'll grow soy the next year. We'll grow a different crop the next year and rotate these crops and let the soil actually dictate what we grow. It turned into... We're going to add more nitrogen in the form of fertilizer. We're going to drive crop yields as much as possible. And then, of course, you had a subsidy that came in that enabled that flywheel. And then what happened is we kind of eroded soil to the point where we're now completely dependent on...
not just genetically modified crops, which people hear that and they get all phosphorylated. What that really means is crops that are now dependent on pesticides. And we run these monocrops and we just do all of these things that produce basically suboptimal plants that are grown in suboptimal soil that feed animals that become suboptimal in their quality. And again, all of this is...
probably not the end of the world if we didn't consume it in excess. So I think it just becomes like another thing that gets layered on the problem is, well, on top of that, and some have argued, by the way, that that's another factor driving our excess consumption.
which is we have sort of a governor in us that is selecting for nutrient quality and if nutrient density goes down you have to eat more of something right like use an example like if you're if you have sort of a central mechanism for seeking out how much micronutrient you want and you're used to getting it in a certain amount of rice
and a certain amount of wheat and a certain amount of meat, but now the actual density of those things is 30% less, would you eat 30% more to compensate without realizing it? So this is one of the theories of overconsumption. Again, I don't think any one theory is entirely correct, but I suspect many theories play a role in this. And so we now have this population that is a significant percentage or obese, morbidly obese.
Almost three quarters are overweight. That's a ticking time bomb, isn't it, Peter, for a country? It certainly seems like it. And then the question becomes, what part of the system breaks first?
So we could talk about different parts of the system. So let's talk about one that doesn't get that much attention, but which is sort of preparedness for war. So we're currently in the last... i would say 10 to 15 years for the first time in u.s history when most people who show up at a recruiting station are failing a physical they aren't actually physically capable to meet the standards of the u.s military so what is the implication of that well
Again, maybe the implication of that is, and maybe the communication of that is irrelevant, right? It might be that we're never going to fight wars again that require hundreds of thousands of soldiers. But what we can say with some confidence today is if we had to, we would have a problem.
Another obvious, I think more obvious implication is the economic one. So as you guys probably know, the US spends more on healthcare than any other country in the world, both in absolute terms and relative terms. In relative terms, we're spending about 18% of our GDP in health. And that's problematic in many levels, but perhaps the most problematic aspect of that is that the rate of healthcare expenditure is a function of GDP.
is outpacing inflation by three four percent and it's been doing that without abating In other words, there was a day when healthcare spending as a function of GDP was 5%. It's now 18%. And that it's growing because healthcare spending is growing faster than GDP. Now I've spent... a lot of time on this problem. So this might be the problem I spend the most time thinking about. And what's driving that cost is many things, but a piece of what's driving it is our health.
It's not the only thing. To be clear, anybody who says you are going to solve healthcare economics by getting everybody healthy is wrong. Well, aging is a massive factor, isn't it? No, I mean, believe it or not, the biggest thing that's driving the U.S. healthcare spending is the consumerism mindset of an American. Okay. Yeah. So technically the single biggest driver, because US healthcare spending is one, well, 85% of it is divided as one third.
drugs, one-third facilities, and one-third personnel. And then 15% is administrative cost that's associated with a multi-payer system. Which of those three buckets are being driven? Because this administrative piece is not being driven by how sick people are. That's simply the infrastructure of our system. Technically, the cost of...
personnel is really more a function of the U.S. economy and salaries here. So it really comes down to facilities and medications. And so it's really the medication bucket that is pushing hard that you could reduce the most by fixing. the health of the population and um but again Every dollar matters when you're at 18% and trying to avoid being 19% and 20%, which we probably will at some point if we don't fix this problem. And then I think there's...
sort of just the personal toll it takes, which is, you know, it's harder to put a dollar amount on that. But there's a ton of stigma associated with being overweight. I don't think there's anybody out there who's walking around who's overweight, who's oblivious to the fact, or who wants to be in that situation. And I think...
Many of these people are quite frustrated. And I think it's, look, I think it's very easy to kind of demonize people who are unhealthy and say, oh, you know, why don't you just buck her up and eat less and exercise more? But I think that's, I don't favor that approach. And I think that- Why not?
I think we need to have more empathy for people. Like, I think, sure, there's always the edge case of the person who just truly says, fuck it. Like, I just want to eat Big Macs all day and I don't care. But I think the truth of it is for many people who are...
in that situation where they're you know they have type 2 diabetes they're overweight um i think they go through bouts and spurts of really trying and not necessarily achieving the success they want we also have to sort of bake in this idea that people i think have different amounts of will and I don't know that you can take much credit for it. So like, I tend to have very high willpower. Did I do anything to hone that? Like, isn't that kind of just like why I have brown eyes too?
I'm the height that I am. All of the characteristics about me are largely innate and I view kind of willpower as one of those. Do you not think it's, I'm sure there's an element of it, do you not think it's also a muscle that you train? Like you train yourself, but why do I train it? You huh? Well, I what gives me the desire to I agree that you practice this stuff. Yeah, and I put it into practice in many things I do but I
This is one of those areas where I really debate free will. I could spend hours talking about it and demonstrating my ignorance. But when I examine things in myself, I tend to appreciate that I can't take credit for much. Luck has sort of given me, you know, maybe genes that are less susceptible.
a stronger desire to do a certain thing. Anyway, all of this is a long-winded way of saying, I think there's an enormous personal toll of these things. I think there's a lot of denigration of self-worth and things of that nature. And I think, look. You see this bubbling to the surface in the discussion around GLP-1 agonists and their derivative drugs, right? Which is the morality associated with using them.
Those are the weight loss drugs. That's correct. These are drugs like, I don't know if they have the same names in the UK. there are newer versions of these drugs that are not even yet approved that look even more potent right so so semaglutide which is the drug that is Ozempic or Wegovi. It's actually the third generation of that drug. Munjaro or Trisepatide was the fourth. And then the next one coming out is called Reditrutide. Looks even better than...
the fourth one, which is better than the third one, which was a log form better than the second one. Point is, these drugs aren't going anywhere in the pipeline of these. There's 20 of these things in the pipeline. But I think as a society, there's a lot to wrestle with because the cost of these drugs is significant. But I also think deep down a lot of people think, is it, you know, there's a judgment that comes with.
from some i think when it comes to their use case yeah sorry finish your point i was just going to say that there's the economic consideration of them as well which everybody brings up pizza how much of this is because i've noticed something so i can't drink alcohol
Because I just can't. I can't control myself when I'm on my alcohol. And if I have one, that will lead to many more. I know that that's why I don't drink. How much of this... is addiction because i've noticed as somebody who has a personality which is obsessive and can if unchecked can lead to addiction i've noticed that when i eat things here I get a little kick that I don't get back at home. And particularly when you look at fast food, when you look at sugar, how much of this accompanies...
putting things in their products, which they know will mean people will get addicted to them and will come back again and again and again and again. I don't think it's a moral thing. I think it's them just trying to boost profits. so a couple things i think that i try to not use the word addiction because it has such technical meanings and i don't want to get into the nuances of what constitutes a true addiction because there's a very clear
clinical definition, but the point is what's important, not the terminology. So if we bracket that the word addiction may or may not apply to food for the average person, your point is very well taken. And I would argue that any American who has spent any time in Europe, and I love being in Europe, will explain exactly what you've just said, which is we have the reverse experience, right?
When we go to Europe, whether we're in Italy, it doesn't matter. You could be in the food central of Europe. You just don't tend to overeat the same way that you can in America. And I have spent untold hours. asking people, why do you think that is?
What is it in the food in Europe that seems to be different? I have never been able to find empirical evidence to support my assertion. It's all anecdotal, but you are yet one more person to kind of ring that anecdote true. I think there's a lot of... things, right? I do agree that in Europe, the portion sizes are so much smaller. And I think that this has been an observed phenomenon that's been done in studies.
When you give a person a portion size, they will often eat past their limits. So there were these experiments done many years ago. where they gave people these drinks, right? So it was kind of like a milkshake sort of thing. And they had one group drinking one drink and another group drinking another, but the one group was drinking it where it was being refilled at a level that...
you know, allowed it to constantly stay higher than it would have been if they were just drinking it. And of course, the question is, are people stopping when they're full or are they stopping when they finish? And of course, these people were drinking more than the other people, meaning that the people who had a refilling drink. So that would suggest that if you put more food on a person's plate, they're going to eat more.
So portion sizes matter. Most people have talked a lot about the differences in wheat quality between Europe and the UK, pardon me, between Europe and between North America. And obviously a big difference here is we use glyphosate on our wheat.
in europe it is not used and so it's really not to me about the gmo distinction but it is clear that there might be a difference in the use of glyphosate for example people talk about how they just don't feel as bloated when they eat things there you've already alluded to the fact that less sugar tends to be used
But also, it's like, think of how smaller the cans and bottles are and stuff like that, right? Oh, yeah, man. We went for a meal with somebody the other day, and you just go to the fridge, and there's a liter bottle of Coke. A liter. And that's the minimum size you can get. That's fucking crazy. Yeah. So I think there are just so many differences. And yeah, part of it is just...
It's our culture here. It's everything is bigger. Everything is better. I mean, but it's everything, right? It's like our cities are bigger. They're more spread out. Look at the difference in the...
I'm sure you've thought of this if you've driven here. When you drive in Europe versus when you drive... in the united states like when you drive in the united states you can shut your eyes half the time the lanes are so big when you are driving in europe you have to be switched on there is no futzing around there's no drifting in and out of lanes like everything is compact
So I just think there's a lot of this going on. But to your question, I agree completely that food science is all about engineering a product. that tastes as good as possible and gets you to buy as much as possible. And moving on to type 2 diabetes. Let me just stick. Do you mind if I don't stick with this quickly? Do you think...
It's very clear from the way you're talking about it, Peter, that we all, I think, would agree that capitalism is a great system, but it comes with externalities. It comes with trade-offs. And... I guess the question is, do you think this can be solved by the market? Because like when we're in L.A., you can get very good food in L.A. It's very expensive.
but if you want to eat very clean you can eat very clean it is available do you think this can be solved simply by the fact that look there's very cheap food and if and it's filling and whatever and if that's what you want you can have that or
if you choose to allocate a different portion of your family budget to food because you care about health, there's a supermarket that only sells really good stuff that's all organic and all this and that. Do you think this gets solved by the market or not? So... This is complicated because you can't disentangle politics from this. And I think it's very counterintuitive to people, to myself included.
how non-linear the effects of agricultural subsidies are on what we ultimately consume. Now, if I were czar, what i would but i also had infinite time where i could do multiple experiments so i had kind of like a parallel universe the first thing i would do is just see what happened when i removed
all crop subsidies i don't believe that's the answer by the way in fact i don't think that will get us where we want but it will perturb the system enough and i would really like to see what would happen right so right now in the u.s Corn and soy are the dominant crops and they are heavily subsidized.
of course corn is the backdrop for most sugar right most sugar in the united states is not cane sugar it's high fructose corn syrup obviously derived from corn I would be very curious to just see what the economic ramifications would be of a complete elimination of subsidies. Then what I'd want to do is perturb the system further in the direction that I would want things to go, right? Everybody knows, you know, show me how a person gets paid and I will show you how they act.
And so if we wanted to create a state where fruits and vegetables, whole foods. So regenerative agriculture as a concept, which we didn't talk about, but we could, became the norm, which meant it wasn't just available to rich people in Beverly Hills, but it was available to everybody. Anybody who was trying to put food on their table could acquire this food. What would have to be true? And I would basically work backwards from that desired state.
to what are the economic incentives that need to be in place. So in this sense, even though I think many people don't like the idea of the government putting their finger on the scale. I think this is one of those examples that, as you said, if you just let capitalism run amok, it's going to purely maximize profits and it has no consideration for the externality of human health.
What I think instead we want is modified capitalism. We want all the tools of capitalism and the innovation, but the government probably needs to have their thumb on the scale in a way that puts a guidance system on that missile. Currently, that guidance system is broken, and I believe it's in large part due to how food is subsidized today. I would just want to...
do the experiments of changing those subsidies in a way that would produce a different desired outcome. So I know it's not a satisfying answer because I'm not telling you what those changes need to be, but it's A, because I'm quite ignorant of it at this point. And B, I'm not sure anybody fully knows. And so if we look at, for instance, type 2 diabetes, and you talk about it in the book now...
When I think about type 2 diabetes, I go, oh, someone's just quite big that it needs to be dealt with and blah, blah, blah. It's not a big deal. But you argue something else in the book that this is a very... It actually opened my eyes to the dangers of being obese and morbidly obese. And there is a whole host of issues that come with this particular condition. Yeah, so in the book, I talk about the four horsemen of death. And the reason I talk about them is that...
Anybody who's listening to this podcast, like they're probably going to die from one of the four horsemen. There's about an 80% chance if you're listening to us right now. You're about to die. And so. And part of that is due to the success of Medicine 2.0, right? Like you're not likely to die giving birth to a child anymore. You're not likely to die of...
an infection. You're not likely to die of cholera. You're not likely to die of influenza. Like the things that killed our ancestors 200 years ago are not the things that kill us. So now we die of cardiovascular disease and cerebrovascular disease, heart attacks and strokes. cancer, dementia, and neurodegenerative diseases, and these cluster or spectrum of metabolic diseases that include everything from hyperinsulinemia.
uh insulin resistance obesity fatty liver disease and type 2 diabetes now what's interesting is that that fourth horseman by itself doesn't kill that many people so if you if you actually just look at death certificates and say how many people on it is when you it's really funny
filling out a death certificate is a complicated, it's much more complicated than you would think. You have to list the primary cause of death and then all the contributing factors. And you have to be very, very technically correct when you do this. So if you were to just look at the 2.6 million deaths,
certificates that were filled out last year in the united states very few of them would have type 2 diabetes as the number one proximate cause of death it's when you look at how many of them have cardiovascular disease cancer, dementia, all these other diseases where a contributing factor is indeed type 2 diabetes. And the reason is type 2 diabetes. contributes so much to each of those diseases by effectively doubling your risk of each of the other three horsemen.
In fact, if you have type 2 diabetes, your risk of all-cause mortality goes up about 40 or 50%. That means if you take an individual with type 2 diabetes, their risk of dying in the subsequent year from any cause is 50% higher than someone without type 2 diabetes. And do we know the reasons for that?
Yeah, we think that the majority of it comes down to what happens when glucose is dysregulated because, you know, that's what type 2 diabetes is. It's a disease of glucose dysregulation. It's a mismatch. between how much glucose is in the bloodstream and how much that person is able to dispose of it, which is just a technical word for put that glucose into their muscles and into their liver and keep their blood glucose levels normal. And if they're...
If the blood glucose levels are elevated and they don't have to be elevated very much, I mean, to put this in perspective, the three of us are sitting here right now talking. We probably have a grand total of five teaspoons of glucose in our entire circulation. That would be normal. If that number were increased to seven from five, we have type 2 diabetes. Wow. i mean it's a subtle difference in other words the body's capacity to maintain homeostasis in this regard is
Incredible. But what are the consequences of that? Well, the more glucose you have in your bloodstream, the more glucose sticks to various proteins in the body. And that leads to certain issues that result in microvascular damage. So you've probably heard of people with type...
two diabetes, they're more likely to have impaired vision. They're more likely to require amputations, get kidney disease, cardiovascular disease, small vessel disease in the brain. And then the other thing that happens is you have higher levels of insulin because you have more insulin. So...
It's a complicated cascade that involves the elevated levels of glucose, the elevated levels of insulin that initially are made by the body, but ultimately usually supplied by the exogenous insulin that they have to give themselves. And then you have a whole host of other factors. including the inflammatory cascade that comes from...
the excess adipose tissue, meaning excess fat cells produce excess inflammation, cytokines that also lead to damage of organs. And there was something in the book that I found incredibly fascinating where you were talking about Tumors cancerous tumors and the effect that glucose had on them and if you've got excess glucose in your body I was there thinking well, what so your tumors are growing basically quicker than other than the normal
Yeah, I think the bigger issue for the cancer cells is probably not even the glucose, although, yes, cancer tumors rely almost exclusively on glucose. It's the other growth signals that come with high glucose, namely insulin. So I would argue that it's the hyperinsulinemia more than the hyperglycemia that is probably the more important relationship link between type 2 diabetes and diabetes.
the increase in the prevalence of cancer. Peter, I want to talk about, in this interview at the end, about some of the answers to these things at an individual level. But before we do, one thing we really want to talk about that you don't talk about in the book is testosterone. We know that men's testosterone is going down generation by generation. First of all, do we know why that is?
There's probably a couple of reasons, but the data would suggest that the most dominant explanation for why basically a... A 30 year old man today has the same testosterone as a 50 year old man did about 40 years ago. Wow. So that's a demonstrable fact. The best explanation for that is probably. the increase in body fat that has come along for the ride in that period of time. And with that increase in body fat comes an increase in inflammation. And with that increase in inflammation, you...
basically are going to make less testosterone. So it's impairing the body's ability to make testosterone. And then also the other thing that happens with more body fat is more of the testosterone that is made is shunted into estrogen. what's called aromatization of testosterone into estrogen is a natural process. But the balance, the more adipose tissue, the more fat tissue you have, the balance of that shifts more that way.
There are probably other factors as well, though. For example, we only make testosterone... when we sleep i mean that's where we have the biggest pulsatile amount of luteinizing hormone and follicle stimulating hormone which tell the body to make testosterone so you could argue although i don't think i have great data for this that anything that's going to disrupt sleep
or degrade quality of sleep especially deep sleep might have a negative impact as well so that could be stress that could be you know phones things that kind of get in get in the way of people's lives but i think that Most of this effect is probably explained by the increase in body fat. Really interesting. And the question that I was wondering about with all of that, we know testosterone affects behavior. And I...
You're not a political guy. You don't get involved in this stuff. But I do think it's an interesting question to think about. This must be affecting how people vote, what policies they support, and therefore the culture of our society, right? I honestly have never thought about it that way. So are you arguing that lower, on aggregate lower testosterone would lead to a shift in one way or the other politically? Well...
When people have less testosterone, they show up differently in the world. They respond to threats differently. They care about different things. They feel more powerful or less powerful. They have a different locus of control. All of these things, right? So... Forgive me for kind of being as blunt about it as I am, but a culture in which sensitivity and, you know, being extra careful and not offending people, etc., seems to be...
taking off, frankly, or has at least done over time, it doesn't seem like much of a leap to go, well, if we all have less testosterone, wouldn't that be the consequence? Yes, super interesting thought. I never gave it thought. I don't know. You'd have to put it in the context of all the things that change. The other thing is, even though testosterone levels are lower than they've ever been, testosterone replacement is also higher than it's ever been. So what we don't really know is...
What is the realized level of testosterone today in the population relative to a decade ago or two decades ago when some of these behaviors started to take hold? Because if natural testosterone is lower, which it undeniably is, but it's being supplemented and corrected, then maybe it's a wash and there are other... But I'm guessing college students aren't taking testosterone replacement, right?
I do believe some are, but I don't know how prevalent it is. But you get my point. Yeah, it's an interesting point. And the other thing I was going to ask you is, this is a question from my wife who wants me to eat less red meat. It's something that kind of is the universal meme that red meat is bad for you. When I went for dinner at your house...
There was quite a lot of red meat on the table from Mark. Now, Jordan was there, to be fair, so you kind of had to do that. What's your take on that as someone who's very health conscious? Yeah, this is one of those enduring examples of really, really... bad science that just never dies. So this idea that red meat is somehow harmful. really began its hold during the 1980s when people began to be aware of cholesterol and the role cholesterol played in heart disease.
And of course, red meat at the time was being compared to white meat. And so back in the early to mid-1980s, there was really a push to move people away from beef to chicken. And the idea was, well, chicken contains less saturated fat, and therefore, on balance, you would have a lower level of cholesterol. And that's true depending on how much of it you eat.
What has given that idea more legs is some of the epidemiology that has demonstrated, though not consistently, that people who eat red meat have higher risks of... you know, type 2 diabetes or cardiovascular disease than people who avoid red meat. So on the surface, you might be listening to this and thinking, well, that seems like a case closed no-brainer. But the problem is...
epidemiology, especially when the hazard ratios are relatively small, is so fraught with errors, right? Epidemiology only identifies associations, but it can never identify causation. One of the biggest challenges with the red meat epidemiology stuff is that people consuming red meat and people not consuming red meat tend to be proxies on average for very different behaviors.
So for example, people who consume red meat on average will tend to consume more processed foods. In fact, much of the red meat that they consume is in the form of processed red meat, like gas station jerky sticks and things like that. People who go out of their way to avoid red meat tend to engage in many behaviors that are pro-health. They tend to exercise a lot more. They smoke a lot less.
engage in other food behaviors such as the consumption of fruits and vegetables to a much higher extent. Now what's interesting is when you strip all of those things away and you normalize for say vegetable consumption, that cancer-causing effect of red meat completely vanishes, right? So in other words, when you just say, let's compare people who eat red meat to people who don't, you're going to get that difference in risk.
But yet when you start to correct for everything, including servings of vegetables in a day, all of a sudden the harm, the supposed harm of red meat goes away. I think there's more nuance to it than that, frankly. And I think it also comes down to the type of red meat you're going to consume. And I don't think all red meat is created equal, just as I don't think all plant... We've already talked about how in Europe...
um there's clearly something different between the bread and pasta in europe and the bread and pasta in the united states and it's not a stretch to assume then that not all meat is the same and i don't you know i mean so much has been said about it i don't need to harp upon it but but i think there's a fundamental difference between consuming farmed red meat and consuming grass-fed red meat that is free of antibiotics and hormones.
Now, again, this gets back to a problem you raised earlier, which is that's a great thing to say when you're well-to-do enough that you can afford to buy those things and not everybody can. So that said, I still think that... that the majority of the literature condemning red meat is highly flawed. I would say that if a person consumes red meat, they should probably make an effort to invest a little bit more and get the red meat that's probably of the highest quality.
And this may be an incredibly stupid and factually incorrect question, but I have heard a lot of talk and read a lot of talk about the fact, the idea that... Actually, there are several types of human beings and some are supposed to be me and others are not Is there any truth to any of this? I have a really hard time kind of accepting that. I mean, I think the the basis for that line of reasoning.
stems from the fact that you know you can trace our ancestors to different parts of the globe right so my ancestors all came from africa yours came from northern europe uh you know there's someone whose ancestors came from asia and the idea was well my answer sisters would have ate more of this and less of it. And therefore, would I be more naturally suited to that? Again, I've just never seen compelling evidence to support what is otherwise a very lovely story.
And so before we move on to our final question, there's the average person who's sitting there watching this or listening to this and they're thinking, right, this is really interesting and this is great, but... How do I become healthier as a person? What can I do to improve my health and to live a longer and most importantly, not just longer, but as you said in the book, healthier life?
Well, it's actually interesting. It's the one thing we didn't talk about today. I mean, there are a lot of things we didn't talk about, but I think the most important thing that we didn't talk about, but it's okay because there are three of the 17 chapters in that book are about it, is exercise. And I think that... Yeah, let's not focus on that. What else can I do? No, I'm joking. Well, I have to make an effort. God, no, no. Well, you know, but for some people, myself included, food requires...
more effort than exercise. So everybody has their own cross to bear in this regard. And for me, food is the biggest cross to bear by far. Sleep comes naturally to me if I do the right steps, meaning it comes naturally to me to be disciplined about sleep hygiene. It comes very naturally to me to want to exercise. I get the reward in the short term of actually feeling good.
For whatever reason, it connects with my cognition where I can tie my ability to do something now to what I did in the gym yesterday. But food is very difficult. Food is a never-ending struggle. for me if left to my own devices i would eat french fries kentucky fried chicken and pizza all day
Every day. I love it so so much. You two would get on. Yeah, we do. You know, you should come round one time. Do you know the last time I was in the UK, I made a point to have fish and chips every single day. I was like, you know what, I'm only here for a week. Like, I'm just going to go to hell. You absolute psycho. Yeah. You see, and that's why you're here. It's the connection. You couldn't stop eating fish and chips. Couldn't stop. So...
But I think that the majority of the health span benefits that we speak of, both mind and body, are going to come from exercise. So if someone said, look, Peter, just... direct me to one thing i would direct them to hey read the chapters on exercise and figure out a way to sort of balance your exercise portfolio around the right amount of strength training the right amount of
cardio training, the right amount of movement training. And I think that that's on a singular level going to pay higher dividends. It's been a fantastic interview. Thank you so much for coming on the show, Peter. Final question is always the same.
What's the one thing that we're not talking about that we really should be? Yeah, even knowing you're going to ask that question, I still can't come up with a great answer. So I would say, what's the... opposite side of the ai bet when it comes to health right so most people that are talking about ai as it pertains to health are taking i would say the most optimistic view right which is
And let's give them reason for saying that, right? So at the time of our recording, a Nobel Prize... uh was just awarded the nobel prize in chemistry was just awarded to the folks at google um that developed alpha fold right so this was a remarkable ai technology that did something I don't know, if you told me this was possible two years ago, I would have said, I don't think so. And I would have been wrong. Which is, and this is nuance, but...
It's an AI that was able to predict the folding structure of a protein only knowing the primary sequence of amino acids. And you might say, well, why is that interesting? Well, that's interesting in that it's a much, much quicker way to help scientists. predict what type of molecule would fit into a receptor, and that's effectively what pharmacology is. So that now takes the first step of drug discovery and makes it really, really fast.
Based on that, I think many people are now saying in 10 years, we are going to be immortal because when you have an AI that can solve that problem today and you look at the pace at which AI is growing. What is it going to be solving in 10 years? It's going to solve aging. So I've met with many people, some of whom I think are incredibly intelligent, who say, look, in 10 years.
It doesn't matter. Just don't die for the next 10 years and it's all going to be okay because in 10 years, AI will have solved death. And I think while that might be a slightly extreme view, virtually everybody I talk with in healthcare says, AI is going to completely change our lives for the better with respect to health. And I just think it would be interesting to hear the bear case on that. And what's the less optimistic case? Not that AI is necessarily harmful.
but that aging is a much more complicated problem than some of these standard engineering problems. And while what AlphaFold did is incredible at the chemical level, it still doesn't solve like... how do you unfold proteins in my body that have folded irreversibly? So we should keep drinking our own urine for the meantime. Exactly. To stave off aging. Just take the hedge. Assume that, yeah. Keep exercising. I literally can't think of anything worse. I actually would rather die.
and drink my own urine for the rest of my life. Peter, I don't know why we ended on that. Thank you so much for coming on the show. It's been absolutely awesome. Not only would, I actually do recommend your book to everybody because it was so transformational for me. I really hope more people...
read it because, as I said, I was somebody who was not paying too much attention to my health. I was busy with work. I sort of thought I was very healthy anyway. It's been genuinely eye-opening and transformational. I think if more people read it, the world would be healthier. All power to you. I hope people buy out, live and read it. It's a fantastic book and keep up the great work. Thank you so much, guys. Appreciate it. All right. Head on over to Substack where we ask Peter your questions.
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