March 16, 2016

Personal

2016 update

Read Time 8 minutes

Yes, I know, I haven’t written a blog post since ‘nam. Unfortunately (for anyone looking to read a new one) I’m not about to start now. But…I do have two things to offer in the place of treatises on cholesterol (yes, I know, I didn’t finish the Straight Dope series), insulin resistance, hypothyroidism, and a dozen other topics (not including “what I eat, circa Q12016”): first, a series of updates (most of you will want to skip this section if you’re only here for the hardcore science talk); second, a few recent podcasts I’ve done.

Update 1: Work, then

I am no longer at NuSI. I left NuSI at the end of 2015 after four great, albeit very challenging, years. The work we started is still going on and in the following years I look forward to seeing the published research as it becomes available to the public (which I am now a part of).

Update 2: Work, now

Today I am working Peter-part-time (30-35 hours/week) on my medical practice, which is located in San Diego and NYC. It’s a very small practice and sort of referral only. It is not a “ketogenic” practice whatever that means (though people seem to ask me that). The focus is longevity and healthspan, for which nutrition is but one of eight components. I love this work more than I can describe, but I have no plans to scale this practice. For now I’m more content to build a few Ferrari’s a year than a thousand Toyota’s. Nothing against scalable, mass-produced reliable cars, but I’m obsessed with perfection, and I can’t perfect much more than a small handful of patients at a time.

The other half of my time is spent working on things I’m not ready to talk about publicly yet, but they are very much related to my interests expressed in the practice.

Lastly, I am (slowly) working on turning my 10,000 word longevity manifesto (circa 2014) into a book. No, I’m not willing to share the manifesto, but I hope it will be worth the wait when/if the book ever comes out.

Update 3: Exercise

Because I get asked a lot on the blog and through social medial…here goes:

I hung up the bike in January 2015 (from a competitive standpoint). I simply could not travel 140 days a year (which I did last year), work 60-80 hours/week, spend time with my family, and be a quasi-serious wannabe time-trialist. And if I could, I don’t think I wanted to. So the past year marks a first, since the age of 13—it’s the first year I have not competed in something. It felt horrible for a few months, but I’m at peace with the fact that I can’t FTP at more than 4 watts/kg and probably never will again (especially since I think it was actually shortening my lifespan, not lengthening it). I will ride socially a couple of times per month, and find the experience fun and humbling simultaneously. I’m swimming Master’s zero to three times per week, depending on my travel (on my two weeks/month in NYC, it’s zero; in SD it’s 2-3). To fill the some of the endorphin void I’ve take up bootcamps—Barry’s in NYC and OTF in San Diego. Lastly, I’ve re-discovered my obsession with heavy squats and deadlifts. So total exercise volume is low-ish by my historical standards varying between 8 and 12 hours/week with nothing constituting “training” except for squats and deadlifts.

Because I know someone will ask, here is my favorite squat/deadlift set: after a thorough warmup of 7-10 sets ascending in weight, the main set is 5 sets of 5 reps, followed by 4 sets of 10 reps, following by 3 sets of 20 reps. Pat Jak introduced me to this set. Another cool variation, which I did yesterday, is ascending sets of 5 reps until failure (i.e., keep increasing the weight until you can’t get 5 reps), then dropping down to a “test” weight (I use 315 on deadlift and 275 on squat) and going to failure. Then, drop to a second, lighter “test” weight (I used 275 on deadlift and 225 on squat) and go to failure once more. Failure occurs when form breaks, not when you fall under the bar and the goal is increase the reps of those test sets each week.

I don’t possess the vocabulary to explain what this does to my glycogen reserves.

Do not—repeat—do not do this if you don’t know how to squat and deadlift perfectly. If you’re looking for an education, I can’t recommend Mark Rippetoe enough. His book, Starting Strength, is a bible for anyone who wants to correctly lift heavy weights. I also plan to take his 3-day course for a little tune up. I’ve been doing these exercises since I was about 15, and was fortunate to be coached by wonderful people, but you can’t be too perfect in these movements.

Update 4: Displacement

People who meet me often assume I’m uber-competitive. Actually, I’m not and I don’t think I ever have been. I’m obsessed with mastery, though, yet I consider that very inward. Swimming and cycling were amazing ways to scratch that itch and so was surgery, mathematics, and virtually everything I’ve ever done. So in another effort to fill that mastery void, now that I’m no longer training hard enough to master anything, I’ve been putting more time into another passion—auto racing.

I could write three or four blogposts about this obsession! Last year I managed 9 full days on the track (Laguna Seca and Buttonwillow, above in spec E30) and this year will probably be the same, but the game-changer is my simulator. Using iracing software and a professional simulator built my Mike Wagner (see pic, below, including my shrine to Ayrton Senna) which is the most realistic sim out there, I can actually spend 60-90 minutes per week in the sim and continue to fine tune every detail of the technique necessary to drive a car at its technical limit. The best part (besides hydraulic pedals)? I can practice with my coach, Thomas Merrill (that hyperlink is to a cool test drive he did in a 458), virtually, for hours on end. I’ve never done anything that requires so much concentration and through which I lose all sense of time. Sometimes I tell my wife I’ll be “simming” for 45 minutes only to have her come out and tell me it’s been almost 2 hours. Another added benefit is that I get to teach my kids about driving while they sit on my lap. Fun for the whole family, really. Except my wife, although she has learned to fly through the corkscrew at Laguna in a Miata. I initially planned to put the sim in our bedroom, but that idea was vetoed in favor of the garage. Better than nothing, but I don’t see why the bedroom was such a bad idea.

On the track, my best blooper so far was an amazing failure of metallurgy going into turn 2 at Buttonwillow. Admittedly I tried to cheat and shift from 4 to 2, instead of 4 to 3 to 2, but still… c’mon…

 

Update 5: Family

Speaking of family, and since I do get asked (thank you very much), my family is doing great and especially happy to see me under much, much less stress than when I was a full-time fundraiser. And as far as kiddos go, it’s still amazing to think there was a day when I didn’t want them (in the abstract, not my actual kids). So glad I was talked into it. The little guy is, officially, a monster. At his 18 month check-up he was 99th percentile in height and 91st in weight. Probably not going to be a great jockey. Big sis adores him and hasn’t (yet) got sick of him. She plays drums like it’s her job and he dances like it’s his.

Update 6: What I eat (the only update you care about…)

In 2015 I did a 6 month experiment of exactly one meal per day (23 hours of fasting, then ~1 hour of eating at dinner). Very interesting. I’m sure I discuss it in at least one of the podcasts, below. These days I’m eating about as freely as I have in 7 years. I’m still carb-restricted by the standards of most Americans, but nowhere near the ketogenic lines of 2011, 2012, and 2013. I almost always skip breakfast, and lunch is usually a salad (“in a bowl larger than my head,” if possible). Dinner is usually a serving of meat with more salad and veggies. I’m more liberal on fruit and even occasionally rice or potatoes. Also, in moments of weakness I sometimes lean into my kid’s crappy food.

The biggest “news” on my eating front is that I now wear a 24-hour continuous glucose monitor (CGM) 24/7. This was the result of one of the most fortuitous flights of my life. In the fall of 2015 I was flying to NYC and half way through the flight, needing a short break from work, I went to one of my favorite watch sites. The fellow next to me made a comment—clearly he was part of the cognoscenti—and we got ultra-deep into watch idiotness. After a while I asked him what he did only to find out he was the CEO of Dexcom, the company that makes the best CGM device on the market. Fast forward a week and Kevin has introduced me to his amazing team (Christy Pospisil is awesome!) and I’m hooked. CGM is a game-changer and it does warrant more discussion than I can provide now. The insights have been staggering. I’m pretty obsessed with it (shocker, yes) and I aim to keep my 14-day running glucose around 90 mg/dL with spot-check standard deviation less than 10 mg/dL. By keeping average glucose low and glucose variability low, I can reasonably assume my insulin AUC (area under curve) is low.

Below is a printout of my last 14 days. As you can see my measured average glucose was 92 mg/dL, which imputes an A1C of 4.8%. At some point I may write about the dozen insights gleaned from CGM (and I think I mention a few in the podcasts), but here’s one: measured A1C is probably directionally valuable (you know, the difference between, say, 5% and 9%), but that’s about it. If your RBC (red blood cells) live longer than 90 days—mine live much longer since I have beta thal trait—your A1C will artificially reflect a higher average glucose. Conversely, if your RBC are large, the opposite occurs. (For those wondering, MCV, which is part of a standard CBC, shows you RBC size).

My A1C in standard blood tests routinely measures 5.5% to 6.0% (courtesy of my tiny RBCs), which poses a problem when applying for life insurance (prediabetic is defined as 5.7% to 6.4%). But with CGM, which is calibrated 2-3 times daily, my imputed A1C, which is much more reliable, varies from 4.6 to 4.9%. Big difference, huh? As an aside, I can’t talk about my beta-thal without hearing my med school roommate, Matt McCormack referring to them as “shite for blood” in the best Scottish accent ever. As if it’s not bad enough having an artificially high A1C… you gotta have shite for blood.

And that’s the least amazing part of CGM. I’m not sure I’m at liberty to discuss the next generation of CGM. Admittedly, not too many people want to wear the device I wear, but in two years, well, that’s when it will get amazing.

And that’s just the tip of the iceberg when it comes to why this device is adding insights and actionable data at a geometric rate. In two years this device will evolve into something everyone can wear.

 

And lastly…

Ok, I can’t think of any other updates so with that below are three podcasts I’ve done in the past 3 or 4 months. By some coincidence all of them have gone live in the past week, which is what prompted me to do this post-that-is-not-really-a-post.

Here they are in the order they were recorded.

  1. Rhonda Patrick and I spoke in Fall 2015. Here is the link to the video, which she nicely annotates. I believe this is also available on iTunes.
  2. Ken Ford and I spoke in January of this year. I was honored to be the first speaker in IHMC’s STEM series. Here is the link.
  3. Chris Kresser and I spoke in February of this year. We planned (before the talk) to discuss lipoproteins, but I don’t recall doing so. Here is the link.

I hope these three podcasts—all of which were really fun discussions—keep you occupied for a while. I have not listened to them, but my recollection is that there will be overlap between them, especially the latter two.

I’ve been asked a lot in the past few months to do other podcasts but I’ve politely declined, noting that I’m a bit podcasted out. I’m sure the energy will return next year, assuming I have something to say.

Photo by Jeff Cooper on Unsplash

Disclaimer: This blog is for general informational purposes only and does not constitute the practice of medicine, nursing or other professional health care services, including the giving of medical advice, and no doctor/patient relationship is formed. The use of information on this blog or materials linked from this blog is at the user's own risk. The content of this blog is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Users should not disregard, or delay in obtaining, medical advice for any medical condition they may have, and should seek the assistance of their health care professionals for any such conditions.

596 Comments

  1. My question is if you have come across many patients with insulin resistance that took atypical anti-antipsychotics.. Hope holidays are going well. Your TED talk brought me here.

    I’m also sharing a bit of my story on having a Insulin resistance. In hopes it will be helpful to you or your readers.

    Back in 2002 when I was 14 years old I discovered I have bipolar 1-when a reaction to Prozac sent me to the psych ward. I had a manic episode triggered by the drug.(I had shown symptoms of bipolar before that) I was treated with risperdal which worked well in bringing me back down. I ended up gaining 30 pounds in month from risperdal. After several months of feeling down and devastated by the predicament I was in. I decided to get active again-I was told the weight would be pretty easy to lose. I started weight lifting, did spinning classes, had a trainer, trained for a backpacking trip. Changed my diet did not lose a pound. Was not in till my freshman year of college when I lost my menstrual cycle that I got diagnosed with PCOS (polycystic cystic ovary syndrome) The weight was gaining was almost uncontrollable. Root cause is theorized to be an Insulin resistance. I was prescribed metformin. Luckily I don’t Ever have to take risperdal anymore other drugs work. Has for my weight still a struggle but stable just like moods. My cravings, Diet unfortunately are affected by my mood at times. One adavatage in being diagnosed so young was very few bad habits and years to develop healthy coping skills.

    http://www.nytimes.com/2009/10/28/business/28psych.html
    My question is if you have come across many patients with insulin resistance that took atypical anti-antipsychotics.. Hope holidays are going well. Your TED talk brought me here.

    I’m also sharing a bit of my story on having a Insulin resistance. In hopes it will be helpful to you or your readers.

    Back in 2002 when I was 14 years old I discovered I have bipolar 1-when a reaction to Prozac sent me to the psych ward. I had a manic episode triggered by the drug.(I had shown symptoms of bipolar before that) I was treated with risperdal which worked well in bringing me back down. I ended up gaining 30 pounds in month from risperdal. After several months of feeling down and devastated by the predicament I was in. I decided to get active again-I was told the weight would be pretty easy to lose. I started weight lifting, did spinning classes, had a trainer, trained for a backpacking trip. Changed my diet did not lose a pound. Was not in till my freshman year of college when I lost my menstrual cycle that I got diagnosed with PCOS (polycystic cystic ovary syndrome) The weight was gaining was almost uncontrollable. Root cause is theorized to be an Insulin resistance. I was prescribed metformin. Luckily I don’t Ever have to take risperdal anymore other drugs work. Has for my weight still a struggle but stable just like moods.

    http://www.nytimes.com/2009/10/28/business/28psych.html

  2. Hi Dr. Attia. I’m curious to hear more about your decision to stop racing bicycles (as a 42 year-old masters cyclist myself). I try my best to stay up on the current long-term endurance training/heart disease connection, both because it’s fascinating and because it’s obviously applicable to my life.

    I’m curious, if you can expand briefly enough in a blog post, what your primary reasons were, and if you have time/interest, your thoughts on this study: http://www.athletesheart.org/2016/04/in-the-medical-news-does-heart-function-suffer-in-long-term-endurance-athletes/

    Lastly, have you ever contemplated (or has anyone else for that matter) a potential link between sugar-based energy supply (sugar being something that causes systemic inflammation in the body) and these seemingly recent discoveries of increased risk of heart disease in long-term endurance athletes (who presumably fuel with primarily with sugar-based foods before/during/after activity).

  3. I’ve been obese since i was 6 yrs old. Now trying ketogenic diet, without a gallbladder. No ill effects on week 2. IBS gone, GERD gone. 150 lbs to go. Reading your page has waned me off the worst fears of this diet, feeling better so far. Many thanks.

  4. Hi Peter,
    As a diet dr.pepper addict, I am looking for yet another reason to abstain…. I think i recall somewhere that you indulge — or at least did– occasionally… Did you learn anything of value regarding glucose readings, insulin sensitivity, in regards to aspartame or any other artificial sweetner while wearing the cgm? If so, i just may have to wear one to solidly break this habit! thanks.

  5. this is probably a longshot, but does anyone know where to find more info/discussion (by Peter) about how his 2015 intermittent fasting “experiment” went (for 6 months he only ate for 1 hour a day, fasting the other 23 !) … he mentioned above that maybe he talked about it in one of his recent podcasts, but i haven’t been able to find anything yet….

  6. Hi Peter,
    I’ve started taking 120mg lithium orotate and have noticed positive effects on my anxiety and mood. What dosage do you take, and is it necessary to take it daily?
    Similar question with phosphatidylserine, what is your daily dosage if you use it daily?
    Opinions on n-acetylcysteine before bed and dosage?

  7. Hi Peter, I sent a message to ‘contacts’ but thought this may be an easier way to get in touch…
    My background is in environmental science but I have always had a keen interest in nutrition and always want to learn more about what is beneficial for our body and how different foods affect our cells and system overall.
    In order to learn more details, I would like to take some sort of nutritional certification course, however, looking around on the internet I often come across courses and coursework I don’t agree with or that is too focused on e.g. raw foods or vegetarian diets.
    Do you have any recommendations for an institute or course that is more in line with a ketogenic diet or nutritional basis? I am located in HI and an online class would be ideal.
    Thank you!

  8. Dr. Attila,

    Any updates on Dexcom? One year ago you said it’ll be a game changer for everyone it two years. Still on course? Seems exorbitantly expensive for non diabetics when insurance will not cover.

    Thanks,

    Tim

  9. Peter,
    Just got my hands on a Freestyle Libre CGM. Any advice/ideas/experiments you recommend with it to maximize my learning? Planning to try a range of foods with it. I’m fat adapted and have been well into ketosis for the last year or so.

    Should be very interesting to see what happens. My friends think I’m crazy.

    • Hi Samantha,
      I got one too and I am doing a keto diet as well. Right now one of my objectives is to improve my sleep to make it more restorative and refreshing. Some nights, specially when I skip dinner, right after I go to sleep my blood glucose goes down to the range of 50s and remains there for around 2 hours (apparently that is the time when most of deep sleep happens). Well I don’t die because I suppose there is enough ketones in my blood. Have you observed something like this and if yes how was the (subjective) quality of your sleep? On a similar topic, do you see any difference in BG during the day as a function of presence of this night time hypoglycemia and/or (subjective) quality of sleep?

  10. Hi Dr Attia,

    I discovered your presentations by chance and could not stop a reading streak in this blog for days. Really great works. As someone who also has this obsession digging into the details and optimisation, I have some questions about keto-adaptation. As you have mentioned previously in some of your comments, you found that after the initial general adaptation that takes about a month (which I suppose is the completion of mitochondrial bio-genesis?), there are actually 2 following stages in the adaptation, which are the big performance improvement 3 months in and “better than ever” performance after 18 months. Do you have some deeper insights about why was that (if I happen to miss something in this blog, my apologies)? Could there be “deeper ketoadaptation”? And how deep can it be?

    Also you have mentioned you have been in and out of ketosis due to several experimental periods that you have conducted (like the IFIK times). Would you say that have done anything to the level of your adaptation? Could lowering protein, zero-carbing, or intensive IF improve/affect ketoadaptation respectively? Sorry about these many questions and hope they dont disturb you much.

    Yours faithfully,
    Lynn

    • Dr Attia,

      P.S. to my last comment, Dr. Lagakos once suggested in this post:
      http://caloriesproper.com/long-term-fat-adaptation/
      that keto adaptation does not get any further after the initial 3 weeks mitochondrial biogenisis period. I wonder whether that is true. Also, is there an indicator of how much does the level of beta-hydroxybutyrate concentration affect the mind status and performance? Like, 0.5 mM is considered ketosis, but 4-5 mM all day long should be something totally different right? Thank you very much.

      Yours,
      Lynn

  11. Hi Peter,
    You are one of the people who triggered my interest in physiology and medical science. Similar to some of the people above I got a Freestyle Libre CGM as well. Such a cool gadget with incredible potential. It is already giving me amazing insight about my physiology. I am of Iranian origin with the beta-thal trait as well and I dream of a platform that allows and facilitates collective experimenting. I think there is a need for paradigm shift about how medical research is done (or at least guided) and how health recommendations/decisions are made. It is not fair to a different minority because they did not manage to move the “average” enough in random trials.

    • Nima,
      I haven’t received my CGM yet, should arrive today. Once I get some data regarding sleep, I will update my post here. Thanks for the idea, I will definitely check it out!
      Samantha

  12. How does your body react to fasting in terms of the rate of fat burn? I think the idea of compounding is very powerful (i.e., consistent, daily actions can lead to outsized result over longer periods of time). That said, I’ve also read and heard you talk about the role of fasting. For example, considering the following…eating 1800 calories/day for 7 days or eating 2100 calories/day for 6 days and then fasting for 24 hours. Calorically, they both amount to 12,600 total weekly calories. Are these equivalent regimes in terms of how your body burns fat?

  13. Dr. Attia,

    I too am into car racing. I currently race autocross and my cousin does road course racing. I am boarderline terrified but also equally excited to start taking my car on a new local road course. However I am trying to rationalize the danger of road course racing. In Chris kresser podcast you mentioned that you believed that it is actually more dangerous driving to the track then it is actually racing. Was this based on an observation or an actual study. I have had no luck finding data on the chances of death and injury from Amateur car racing/track days in comparison to day to day driving. Thank you.

  14. Hi Peter,

    Can I ask for what reason you use sleep supplements (particularly Doc Parsley’s sleep remedy)?

    Also, how do you use it: dosage, timing, frequency?

    My sleep cycles are crazy and I’ve been looking for ways to improve my sleep habits. Sometimes I use melatonin by itself as it helps falling asleep when otherwise I wouldn’t be able to.

  15. Hi Dr. Attia, I wrote quite a lengthy comment on your main blog page, but I saw that you haven’t replied to some of those in a few years! haha 🙂 Anyway, if you would please take a moment when you can to read it and reply, it would mean a great deal to me! I have gestational diabetes and am desperate for answers that can be backed by science! Thank you so much!

  16. Hi Peter,
    As a Type 1 diabetic I’m also obsessed with CGM and constantly monitoring my BG levels. (CGM and Insulin pump has enabled me to test usually around 5.3% A1C with a carb restricted diet). I’m interested to know what are the peak values of BG you’ve seen after meals that were higher in carbs in your case.
    Unrelated and if you can spare to comment, I was wondering if you’ve ever seen/considered any data suggesting a link between T1D and Psoriasis
    Thanks for your time

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