March 16, 2016


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.


  1. My question requires a bit of a lead up. I have felt not quite right for about 10 years ……ever since I discontinued the depoprovara needle for birth control. I actually felt great while I was on that much to the surprise of the Dr. who put me on it but I felt after all the years I took this needle that at my age it was probably time to take a hormone break. As soon as I stopped this medication I started to feel off and I also started to slowly gain weight. Not a huge amount all at once but about 8 pounds a year until after 10 years it was an 80 pound gain. I had lots of other symptoms too during that time from an itchy leg rash to headaches to constant yeast infection to hair loss to dizzy spells and heart beat flutters and edema of the feet and ankles. Before that I had remained the same size for 30 years. After medical test upon medical test I was diagnosed with Diverticulosis which turned into Diverticulitis 3 times, Estrogen Dominance, Metabolic syndrome which required me to start on Metformin and then a large Ovarian Cyst and a uterine Fibroid. In February both Ovaries and Uterus had to be removed. Neither were cancerous after the pathology and even though I have had a few hot flashes I have so far remained hormone free. Because of all my other issues I had already been eating in a fairly restricted manner since sugar, grains and young dairy were bad for all of my conditions. Even though I had been eating this way I never really lost much weight. After my surgery I decided to really buckle down and try to turn this train around and I started to lean towards a more ketogenic diet. I also started to get more strict with my caloric intake fasting for 18 hours a day and eating in a 6 hour window and trying to keep my calories between 800 and 1200 depending on how much exercise I get in the day. I have lost 24 pounds since February but my concern is that my fasting blood sugar readings have gone up even on my Metformin and the Edema of the feet and ankles is there everyday. Not crazy high but between 8 and 9 and sometimes higher for my morning fasting reading. My doctor just tells me to loose weight with no advice on what more I can do. My endocronologist wants to do a gastric bypass. I don’t want to do that. I feel I can get this under control if I just know what exactly I’m not doing right. At this point my macro ratios are about 10% carbs, 30% protein and 60% fat and I try to drink about 6 to 8 glasses of water per day. I have been trying every home remedy I can find as well from apple cider vinegar to cinnamon to magnesium to alpha lipoic acid and green tea and raspberry ketones and ginger and dandilion. I just need someone look at what I’m doing and tell what Im not doing right. Please Help me ……I am desperate.

    • Oh P.S. if you ever needed someone to try experiments I would be interested…….Just not surgery. I need to lose at least 100 pounds ………….the 80 I gained and I was already over weight to begin with. More would be even better.

  2. Your information has helped me significantly. I was always pretty lean pre-pregnancy, but craved&gained a lot during that phase. I had no success losing postpartum weight despite lots of running, lifting, and calorie cutting. It was phenomenally frustrating and my thyroid was tested 3 times, all results being normal. If I hadn’t read about insulin resistance, I’d still be spinning my wheels. I’ve had great results since starting keto a couple of months ago.

    What I’ve found, though, is that many folks – otherwise seemingly knowledgeable folks in the realm of nutrition – seem to believe that this is some kind of nutritional voodoo. And they’re quite defensive about it. I don’t care because it’s working for me, but I wonder if you know why it’s treated as such blasphemy. Why are people so attached to the calories in/calories out model as the only equation?

  3. Peter,

    If one is experiencing hypoglycemic feelings (dizziness, low energy, anxiety) after 30-45 minute runs while being in ketosis, what are some possible paths of troubleshooting to take next, aside from adding carbs back in the diet? Is exercising in a fasted state one of those paths of experimentation?

  4. Dr Attia

    I am writing you from Bogotá, Colombia. I just wanted to thank you for sharing such an amazing amount of information, what I like the most is that you support everything you say with science and experimentation, however, always being humble about wether people should believe you or not. In my case, I find every bit of your information (blog + podcasts) really useful and mind opening. It is such a shame that in third world countries there are not as many studies about insulin resistance+Ketosis+Metabolic desease and so on. Longevity is a field that we all want to learn about, and do something to increase. Thanks again and I hope you keep multiplying the knowledge as you have been doing so far.

  5. Dear Dr. Attia,
    I am curious to know if the keto diet will increase a woman’s vulnerability to breast cancer with regards to alcohol ingestion. I read that ketosis competes with the same enzyme that breaks down acetaldhyde. Would that lead to increased levels of acetaldhyde in my blood and or cells? Wouldn’t this increase the risk of breast cancer and if so, why is this not being addressed in available information regarding the risks of ketosis diet and women’s health.
    Thanks much, Heidi

  6. Hello Pitter
    Thank you for running that blog. I’ve read quite a lot I thought, but then found out the blog is huge!
    Anyway I haven’t found any hints to answer my questions. Would be grate if you’d have anything to say about them.
    I’ve been on keto diet for 2-3 months now. Now, on my 3rd month I can definitely see only one improvement – the flaking on my forehead and between brows has vanished! I have sever dandruff and it has decreased but not vanished yet.
    But the questions I have are about other things.
    1. When I eat fat, just pure fat like melted fat or lard, or melted lard – I immediately feel sick. The fat has not even made its way through esophagus, but I feel sick anyway. I remember I have had it since my teens. I checked my liver and gall-bladder – nothing. They found a bit of bile esophagitis but not so big to make any problems.
    I love fat, lard and I can eat it with bread – no problems, but also not much, then I get that sick feeling. And now I don’t eat bread of course, and lard, fat, mutton fat make me feel sick.
    May be you have anything to say about it?
    2. We live in a relatively hot climate – we live on Cyprus. Since May till October it’s quite hot here. And how to make yourself eat fat food? Usually I don’t really eat during the day. Morning: 2 espresso half by half with 30% fat cream; on lunch I can have bacon and eggs, not much; and the dinner, yes, it’s a real meal for me. But the more hot the less fat/meat you want to eat…
    What to do? How to stay on keto-diet with all that? And I also think with such a ration I lack some calories I have to get according to my weight…
    Thank you!

  7. Peter,

    I always enjoy your posts. Thanks for taking the time.

    Are you still using UCAN? If so, does it raise your glucose significantly?

    • I don’t train in a way that requires supplemental glucose any longer, but I should do a test with the CGM. I’m guessing it will have minimal impact.

  8. Peter,

    Is Insulin Resistance reversible or not, before diabetes strikes? I am looking for the peer reviewed medical literature on this subject and cannot find it. I read extensively how blood glucose and Hem A1C can be “managed” and brought in the proper range with LCHF or fasting, even “cured” according to Dr Jason Fung (a play on words it seems). The LCHF diabetics crowds say that they are doomed, that IR will never change, the fasting crowds believe they will recover. But does the insulin resistance itself DIMINISH with time, when the body is in an environment of low glucose and low insulin? At least before diabetes? Are there studies on the subject?

    Thank you! Virginie

  9. If you ask me I have followed you for several months. In reality that means three at most. Your view on nutrition and exercise have stoked a fire in me that was there but just burning coal before. I love driving cars. The fact that you can give me so much knowledge on something I was less aware of (nutrition) and relate on cars (I have owned two E30’s) just really makes me happy. I look forward to your work with NuSI and I know you will get results. Thank you.

  10. Peter,
    I owe you a debt of gratitude for your work. Let me provide you a little background. I am 48 year old with two children and live in Vancouver. I was pretty fit into my mid-20’s and then got busy with life and my exercise consisted of cycling and an annual 160km bike race in Penticton BC. I started playing lacrosse again last year and promptly pulled my groin. I am 6’1” and my weight creeped up to 230lbs one year ago. It was at this time that I came across your information and started to follow keto. Fast forward one year and I weigh 175lbs resumed playing lacrosse and am keeping up with kids over half my age. Losing the 55lbs was relatively easy and I continue to follow keto for the consistent energy levels and how my stomach feels.
    In my rehab. journey with the groin injury I came across Starting Strength last fall and squats and deadlifts have done wonders for my groin injury as well as knee pain.
    The keto information that you provided on your blog was the foundation for the changes that I have made and I can’t thank you enough.
    With kindest regards,

  11. Hi Peter, I was wondering if, after using the CGM for a few months and paying close attention to it, you would be able to extrapolate your blood glucose levels within a reasonable degree of error based solely on subjective criteria (how you felt at a given moment). Basically, can you wean yourself off of it and just “listen to your body?” Lastly, what single item of food did you find MOST detrimental to your blood sugar, and what surprisingly had little effect despite seeming like it would? Thanks so much for your time.

  12. Hi Peter, interesting changes in your life. With a toddler now we have relaxed our strict VLC diet ourselves. Some questions related to the discussion with Rhonda.

    1a) Do you monitor anything else than Glucose on a regular basis?
    1b) In extension: Do we know in 2016 what blood labs can be done to measure effectively your inflammation load? (probably it is not CRP but more advanced stuff) – that which affects your longterm cancer risk, probably ALZ risk, ageing speed…

    We know what impacts inflammation: low carb, moderate activity, nutrition, meditation, sleep, low blood glucose, low insulin etc – but what should we measure in 2016 (generally available labs) to validate how much inflammation / bad load we really face (due to stress, toxins, suboptimal nutrition, etc).

    2) How do I get the Dexcom without Diabetes?

    3) Is there any proxy test for ApoE-related risk or ApoE expression for E3/E4 and E4/E4 ?

    • Small question in extension: Did you learn anything from monitoring your glucose 24/7 that is worth sharing?

  13. Wow to your squat and deadlift workout. That is a huge amount of volume, especially for deadlifts, 20+ sets???? I was thinking you were probably going pretty light, until you mentioned backing off to a ‘test’ set at 315. So not only is that a lot of sets, but it sounds like you are using a lot of weight given your size.

    Since you mentioned Rippetoe, his program has you work up to a one top set of 5, and maybe you do a 10% backoff set if you are craving some additional volume. And from following his posts, I know his personal program is quite minimal – he squats OR deadlifts once a week, alternating between the two, basically working up to a heavy top set of about 5 reps. Of course, he is close to 60, but still… quite a contrast to the volume you report. Just curious about the rational for doing so much? For most people, the cumulative low back fatigue would likely set up an eventual injury.

  14. Hey Dr A – “Ever since Kresser” . What I am saying is that once you did a podcast with Chris Kresser I have gone down the rabbit hole exploring the differences of allopathic (conventional) versus functional/integrative medicine . I am an FP in practice for 30 years . While I have respect for the idea that conventional medicine falls so short in so many ways, I am deeply suspicious of the sales oriented approach I see in so many of the integrative practitioners – Kresser, Romm, Hyman , Ruscio, Brogan to name but a few . All of these docs seem to be selling their services and advice in an aggressive manner. I have read several of Chris’s ebooks on various conditions and I find them thought provoking at times but I also believe he cherry picks the info he wants out of studies ( and don’t we all , I know ) . I read Kresser but I also hear John Ioannidis reminding me that so many studies are flawed .
    What do you think of the integrative medicine movement?

    • Not all that interested it “nice neat” summary titles that don’t mean anything. There are good and not-so-good doctors under any set of titles. This one is no different.

  15. Hi Peter, what do you think about honey as a substitute for table sugar? I read that you use xylitol in your icecream recipe…is that your preferred sweetener? Since honey is more slowly absorbed and natural, can it be a replacement for sugar in moderation? Thank you for sharing your knowledge

    • Not sure what this means. I’m in favor of using hammers when the task is putting a nail into a piece of wood, but not sure I’d say I’m promoting hammers.

  16. In the revised talk you briefly make a comment something like “Don’t even get me started about salt” which made me wonder if there is a whole low-sodium lie that has been perpetrated, much like low-fat lie-fat you discuss in detail. Any suggestions of where to start reading about that topic?

  17. Hi Dr. Attia,

    I have a simple question for you: what do you think is the most promising area of study in human health at the moment– nutrition, biochemistry, public health, or something else? I’m trying to figure this out for myself applying to graduate school, but I was wondering if you could lend me your wise opinion as someone I consider to be ‘the most’ ‘in the know.’ In other words, if you were to get a M.S./PhD what would it be in and why?

    I would greatly appreciate any thoughts you have on this manner!

    Best wishes, Stephen

  18. Dear Dr. Attia

    Thank you very much for creating such interesting and informative content !
    I would be very grateful if you would find the time to answer these two questions.

    – Do you think physiological insulin resistance induced by low carb eating should be avoided in the quest for longevity ?
    – If yes, this should mean that someone with physiolocial IR should increase their carb intake until their FBG lowers into a more favorable range, e.g. sub 90mg/dl as mentioned during your pod cast with Ronda Patrick ?

    Background (if needed):
    – I’m 31 and quite muscular and lean (clearly visible abs).
    – Paleo diet but including rice and potatos since 5 years
    – Roughly 150g of carbs per day, Starches only for dinner
    – Physically very active: Strength training 1-2h per day.
    – HbA1c 4.6%
    – Fasting insulin 5.1 mIU/L (one time reading 2 years ago)
    – Fasting blood glucose from 100-120mg/dl
    –> self diagnosed physiolocial IR as increasing carbs brings the FBG down

    Thank you so much in advance!
    Best wishes from Switzerland

  19. Peter,
    I’m devouring this website after accepting and denying my metabolic syndrome for 20+ years. Yours is an inspirational story in many levels and I’d like to express some commonality with you, though I’m 12 years older. I can work out like a fiend and still have a chubby physique. I wish I’d have listened a little closer to Dr G Berenson, principal investigator of the Bogalusa Heart Study, who you cite indirectly in your post on fatty streaks in childhood. It was a yearly update in 1980-84 for us. Seeing you’re from Hopkins, I had Donlin Long as one of my board examiners. Not one of your immediate mentors but an icon from Johns Hopkins. Finally, Mark Rippitoe is a good friend. I’ve worked with him on and off for years and you will learn how to do a squat and dead lift, believe me. If you come to his town I’d love to meet you.

    • Wow, John, that’s a lot of cool connections. I never worked with Long b/c in general surgery we only did one month of neurosurgery, but his legend was enormous and technical proficiency often discussed. How cool that you know Ripp (I don’t…just a few email exchanges, but I’m a fan).

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