#307 - Exercise for aging people: where to begin, and how to minimize risk while maximizing potential

Peter Attia
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We'll define that as my cohort and up, 50 and up, who realize the importance of exercise but are wondering if it's too late for them to start. This could be because they've never trained or they're worried about injury. They have no idea how or where to start, or they used to exercise when they were young, but they've kind of got away from it and they're just trying to figure out what to do. As such, we wanted to create an episode for these people. People above 50 who haven't been exercising at least recently, want to start but don't know where to begin.

In this episode, we speak about exercising in that age range as it relates to all four pillars of exercise and dive into not only why it is not too late, but what one can do to start exercising, minimize injury risk, and maximize potential. This conversation will be a little less technical than some of our AMA's. I wanted to try to keep it a bit more conversational, and what we've done to accommodate that is included many of the studies that support the observations and points that are being made in the show notes even if you're not in this quote older slash 50 and up age category, most of you likely know someone who is like a parent, and you may find this, hopefully something that you can share with them and help them to start exercising. So without further delay, I hope you enjoy this special episode of the drive.

Nick
Peter, welcome to a special episode. How you doing? Very well, thank you. So today's episode is special in that it's kind of shot like an AMA, but it's going to be available to everyone. And what we're going to cover is one of the most common questions that we see come through day in, day out to the website is whether people who are, quote unquote older, let's say just for general purposes for this conversation, 50 plus, who realize the importance of exercise but are wondering if it's too late for them to start.

And this could be whether they've never trained or worry about injury. They don't know what to do or how to do it. Or they just think, you know what? It's too late for them to really make a difference. And so we wanted to create an episode for that group, 50 plus, who have not been exercising but want to start.

And although much of what we'll talk about applies to anyone in that age category, it also can apply to anyone of any age who is deconditioned and looking to start slow. With that said, too, anyone who's younger most likely has parents who might be in this position, and this could be a good episode to send to them to encourage them to start. And so how we're going to structure it is a little less technical than some of our AMA's and much more conversational as to how you would speak to these people if they were your patients and came to you and were asking you these questions in the show notes. Well have the studies that you talk about, well link to them, well link to other content that goes much deeper, but this will be a little bit more on that conversational side. So with all that said, anything you want to add as someone who is now in the quote unquote older category as well.

Peter Attia
Yeah, my wife likes to refer to me as an older gentleman now. So. That's right. I'm in the over 50 category. Not just 50, but over 50.

So a couple things. One, as we thought about putting this together, the goal initially was to have no figures, no studies, just really put all of that in the show notes. But let us talk. And I've sort of begged to have a few figures because I do think that there are times when a picture just says a lot. So for folks who are listening to us, there's going to be a few times when I'm going to reference some figures from studies that I think really do a lot.

A couple things to state is that we'll talk about this in detail. But we talk about 50 being a turning point. I think another really big turning point is 65 plus. And again, we'll get to some of these things, but we really start to notice reduction in strength at about that age. We start to see vestibular changes that occur around that age, and that probably contributes significantly to something we will talk about, which is the risk of falling.

So while I think everything we're going to talk about is going to be relevant to anybody who's over 50 and untrained, I will probably call out specifically areas where when we get into that 60 to 65 year old camp, we want to be even more mindful of things. And so I think to start, you've spoken at length about the importance of exercise for longevity. So I don't think we need to start there. But let's say someone heard that message is in that 50 plus 65 plus category, hasn't been exercising, and they come to you and say, is it too late for me to start doing this? Is it too late for me to worry about this and start making changes?

Nick
I think it'd be helpful for people first to hear, how would you even respond to that? I've had the same response largely for many years now. So I realize that some people will have already heard me say this, whether it's on another podcast. But truthfully, I havent come up with a better analogy yet. And its really the analogy of saving for retirement.

Peter Attia
So if you could be talking to somebody whos in high school or college, and you were talking to them through the lens of being a financial advisor, their fiduciary, what would you say? Well, you would say, listen, theres this really magical thing called compounding that Einstein basically said was the 8th wonder of the world and you want to use it to maximum advantage. And to do that you should start saving immediately. When you get your first job, you should be saving. If not, certainly by the time you get out of college, you should be saving.

And if you do that, you don't really have to be that brilliant about it. If you put all of your savings into an index fund at the age of 22, the probability that you are not going to be set when you retire is so low. So that's great. But what happens if you're talking to somebody who's 45 and due to life circumstances, like they just haven't been able to save, they haven't made enough money to even have some disposable saving income, or they've saved and lost or invested badly or something like that? Would you say well, too bad.

No, of course you wouldn't. I guess the point here is it is never too late to start saving for retirement. But you must understand something, which is the longer you wait to start, the more you're likely going to have to save, the greater return you're going to need, and therefore probably the greater risk you're going to take. So it's never too late to start saving and it's never too late to start exercising. But I want the message to be, don't wait because of some reason and say, well, I'm going to wait till I'm older because.

So anyway, to me, that's the best way to think about this. I think it will be helpful for this conversation because we'll touch on these various aspects as it relates to exercising this age population. But can you just remind people of your four pillars and kind of how you think about each of those pillars individually as someone is aging? Yeah, and sometimes I think of it as three or four, but I think I'd write about it as four, so I'll stick with that. But it's basically stability, strength, aerobic efficiency, and peak aerobic output.

You could argue, well, those are just kind of a continuum. And so I would say, sure, but let's not get lost in the semantics. Those things, if you define them the way I do, kind of constitute everything. Again, stability is kind of a broad term, but embedded within stability is everything that enables you to dissipate force safely, everything that enables you to have balance and flexibility, because, believe it or not, those come from stability. If you have balance, by definition, you have stability.

You can't have balance without stability. You can't actually have flexibility without stability. We think of training as having a purpose, and of course, different types of training factor in to these different activities. So there are some types of training that really kind of myopically hit one of these things. So if you're riding a bike like I do for your zone two training, well, first of all, riding a bike is a very one dimensional activity, basically no degrees of freedom outside of you pedaling the crank.

And if you do it at a fixed power output that meets the criteria for zone two, then you're very narrowly targeting that. You're doing very little for any of the other systems. And then conversely, there are other types of training, like rucking with a heavy weight on hills, where actually you're targeting all four of those elements. That requires tremendous stability, moments of strength, large segments of aerobic base or aerobic efficiency, and moments of peak aerobic output. And even anaerobic output.

So thats just something to keep in mind. You mentioned at the outset theres a few graphs that you think will be important. I think its a good spot for us to pull them up, which is one looking at the decline of muscle as we age so people can visually see what that looks like. And then one looking at Vo, two max across different age brackets. I'll share my screen here and pull them up, but I think it'll be helpful for people if you kind of talk through them and how you look at it through the lens of this conversation.

So this is a figure that I fought like crazy to include and outlive, and I got overruled and just kicked in the groin. No way. This figure was going in the book. So it really makes me happy to be able to show this figure here. The figure for those who are not watching.

It's basically four graphs. And two of them are for men, two of them are for women. Two of them demonstrate fat free mass, which is a great proxy for muscle mass. And two of them show spontaneous or deliberate physical activity. In that sense, you can think of it as a two by two, male by female versus activity and fat free mass.

And then each of these has kind of an x axis that shows age. Okay, so what one notices when they look at this is that fat free mass rises up. So that is, lean mass kind of rises pretty significantly from birth till about the age of 25. And then it slowly starts to go down. By the way, this is true for males and females.

Males are on the right, females are on the left. So you'll notice that from age 25 to 75, there is indeed a gradual reduction of lean mass. But then something happens at the age of 75, which is the falloff in lean mass becomes much more significant. It's actually even more noticeable in men, presumably because they're starting from a higher baseline. But this is clearly a curve that has three segments, birth to 25, where you're gaining, gaining, gaining, 25 to 75, where you're slowly losing.

And by the way, we know the numbers. We know that that's actually happening at eight to 10% per year and then 75 and on where you fall off a cliff. So now let's look at the lower figures. The lower figures show physical activity level. And you can see that a very similar trend occurs.

It tends to peak a little bit earlier, so it's probably peaking in late teens and early twenties. And interestingly, it doesn't have a huge fall off between the ages of roughly 20 and 75. It actually stays relatively constant. If anything, it probably dips a touch in middle age. That might have to do when we're at sort of peak work and therefore not as busy physically.

But again, you notice what happens at the age of 75, which is physical activity level drops like a stone. And of course, this begs the age old question, which is, which is the chicken and which is the egg? Because, again, there is an unmistakable relationship here between physical activity and muscle mass and age, and something very noticeable happens at the age of 75. Of course, data like these cannot give us causality. In other words, can't tell us which one's causing the other.

But I think anybody who's observed people at this age would come to the conclusion that there is bi directional causality here. In other words, as we lose muscle mass, we become less active, and as we become less active, we lose muscle mass. And there's one point that I will make in addition to this, which actually came from a very recent interview I did with Luke Van Loon. So that's an episode that you can go back and listen to in great detail, if you haven't already. But Luke made a very interesting point, so interesting that I was scribbling it down as he said it, which was that data like these were replete with these sorts of data that show population based reductions in activity of aging individuals always make it look like it's kind of a gradual, continuous curve.

Even if it happens precipitously, it's still a continuous curve. And what Luke pointed out is, well, actually, that's true at the population level, it's not true at the individual level. At the individual level, it is a series of big, discrete drops. And so when you smooth out thousands of people with big, discrete drops, it looks like a smooth drop. And what it really comes down to is once you reach a certain age, even minor setbacks become permanent setbacks.

And that's the thing we're going to talk about, but we have to be able to avoid that situation. So I'll give you one example. People have long heard me talk about the idea that once you reach a certain age, like 65, and if you fall and break your hip or femur, the probability of death is really high. I mean, it's on the order of 15% to 30%. What often gets forgotten there, even though I try to always mention it, is of the survivors, meaning the people who don't go on to die.

Within twelve months, 50% of those people never reach the same level of function again. That's an example of why these curves are probably not smooth, but in fact, have these discrete step offs. And now, do you want to talk in the same way about how you talked with the muscle and activity decline by looking at Vo two Max? Yes. So, again, apologies for those not watching, but rather listening.

Again, please take a look at the show notes. But here you can see a table that shows exactly what is happening to Vo two max as we age. Now, the purpose of this table, of course, is to show you something else. The purpose of this table is to show you, basically the quartiles of Vo two max by age. So the way this table is broken up is that low, below average, above average, and then high and elite combined represent the four quartiles of Vo two max.

The difference is that elite peels off the top 2.3% for each respective age and sex. And so we could talk about what that looks like. But I think a more important point, and the purpose of, I think, showing it here, is to give you a sense of how every one of these categories falls. In fact, what I think is most illustrative is to just look at the elite category. So, again, these are the top 2.3% of the population.

So, for example, if you look at a woman in her late teens, the top 2.3% would have a Vo two max greater than 53 oxygen per kilogram per minute. And you can see that that will fall such that by the time a woman is 80, to be in the top 2.3%, she would have to be greater than 30. But what's interesting is 30 places her in the bottom quartile. For the late teens, it would place her at about the 25th percentile for someone in her twenties. So the implication here is that regardless of how fit you are, you can still expect to see a precipitous drop here.

And as I've talked about many times, and certainly my patients are probably very sick of hearing this, the reason we want to see people, if they want to live a completely encumbered life into the final decade of their life, and that's a big if. Not everybody necessarily has that type of an aspiration. But if your aspiration is indeed to basically be able to do what you want without limitation, climb a flight of stairs, carry a luggage up a broken escalator, go for a hike, you pretty much need to be two decades younger at the elite level if you're thinking you're going to live to be about 90. So, anyway, this hopefully provides some illustration of why that's the case. Yeah, Peter and I think that's really helpful for people to kind of see and hear.

Nick
And it's almost the why. So the why you should care about this and why no matter what age you are, no matter how, quote unquote, old you are, you really do want to continue to think about this. And so now we'll get into a lot of what people are probably really curious on is the how. So you've convinced me I need to care about this and I should do it. But how?

And so I think the first question that would be helpful here is, you know, what are the most important aspects of training if you're starting or even returning to exercise in later life. So this could be people who have never exercised, or this could be people who exercise all the way until they were 40. Family life got busy, they took 10, 15, 20 years off, and now they want to get back into it. I mean, I think there's a lot that one could say here, but I think you would want to start from the principles of exercise variability and movement quality will always trump volume, load and intensity. So I would say that I think most people listening would agree that that's an obvious statement to make for someone who's new to the game.

Peter Attia
But this is an example of something where I would say that's even true for someone like me. I have a very high training age. That's the term that we use when we're assessing patients to understand how much volume they've done and over what period of time. Basically, with the exception of one very bad injury, zero interruption in very high volume of training since the age of 13. And yet, as I'm now in my fifties, I realize I need to be much more attentive to these principles of exercise variability and movement quality.

The reason is, quite simply, I'm much more prone to injury today than I was before. And so I have to think of ways to challenge myself that are not just load dependent. And that doesn't mean that I don't still push load in complex movements like a deadlift. I do, but I'm clearly not going to do nearly as much load or volume in those regards. And I am going to want to challenge myself.

And by saying this of myself, what I'm really saying is everybody should be thinking about this, especially at this age, in terms of circuit training exercises, where you're doing more than one thing at a time. An example of this might be that if someone were just starting out, I would want to see them doing more body weight exercises that are slightly more complex movements. So, for example, a step back lunge is an important thing for them to be doing, even if it's just body weight versus just working on a leg press with heavy weight. So again, there's a time and a place for using machines, and I think we'll talk about why. I think machines are a very good thing for someone starting out because they control the range of motion.

But we must be able to mix that in with more complex movements that are variable in more than one plane. And for those movements, we obviously want to deload them so that we just begin to do the neuromuscular training. With that, let's say potential patient over 50 coming to you and saying, I want to start exercising. How are you going to start to think about the structure of the programming that you give them? Because again, you mentioned the four pillars and there's different areas you could start.

Nick
So how do you think about that person just taking that first step to exercise? You know, it always starts with a question that is obvious, but it sometimes is overlooked. And I have to be honest with you, this is something that even I think I overlooked a lot years ago. And that is you have to come up with something that is realistic for a person. Because the most important goal when you're returning someone to exercise or when you're starting someone from scratch is you want them to be able to look back in three months and view this as a positive experience.

Peter Attia
Nothing else matters. If that is not true, if in three months youve improved them by every objective metric and they hated it or theyre injured, well, I just dont know how to view that as a success. So people are going to be very different in terms of what their appetite for beginning is. But because were focusing this discussion on people who are not like me, they arent lifelong exercisers and therefore by definition theyre either starting from scratch or maybe coming back to it after a long hiatus, you have to assume that their appetite for training is not going to be seven days a week, 2 hours a day. And therefore what I really want to focus on is the habit of doing something active daily.

And that doesn't mean training every day, but it means at least walking or doing something active. You're going to evaluate them based on their fitness level, their level of conditioning. And again, at the most extreme level, if it's a person who's never done anything and is completely deconditioned, it's really going to be about walking. And that's about it. And it could be as little as 5000 steps per day, every day on relatively flat ground.

And of course, there's so many ways to progress this. If a person is a little bit more conditioned, I do like to put weight on them out of the gate. I'd like to have them do some rucking. We're not talking about putting 60 pounds on their back. It could be 20 pounds on their back, but getting them moving under a little bit of load.

Again, there's lots of other things to consider here. So, again, if a person is open to starting with some bodyweight exercises, that's a very helpful way to begin doing things. It doesn't have to be complicated, right? It could be box squats, wall sits. Isometric things are much safer for individuals who haven't done conditioning in the past than isotonic movement based, meaning strength movements where the muscle is changing length.

I don't know if you want to talk about more now versus later, but again, I have strong thoughts on how to begin cardio training. Weve spent a lot of time talking about the importance of vo two max when were working with a patient who hasnt done training. We do not do vo two max workouts. I do not believe in starting people with interval training without building an aerobic base. And the aerobic base, of course, that zone two, you want to start building that in a manner thats consistent with where theyre coming from.

So that might just be, again, walking, that could be incline walking, that could be riding a bike, and then even within riding a bike. How do you do that? If a person doesn't have the lower back flexibility and strength, it might even be on a recumbent bike as opposed to just a regular stationary bike. So all of these things are considerations. But again, if you forget everything else, remember the following.

You want to make sure that in three months they feel better, they notice that they are fitter and their appetite to exercise has grown. That's the most important thing. If you're viewing this both as a participant or as a trainer, lets continue. Down that aerobic path that you kind of mentioned there. And so I think the first thing people are curious about is, what do we know about the ability to improve aerobic capacity?

Nick
Is that something that can be improved in someone who is older and untrained? Yeah. And thats, to me, the most amazing part of this is how malleable that system is. In fact, I think you could make the case that the physical system, so aerobic capacity strength is even more malleable than our cognitive systems. And we know that our cognitive systems are quite malleable.

Peter Attia
Again, I didn't want to load this with too many stats and studies, but I think this one is worth mentioning. And obviously we can, in the show notes, give you all the granular detail. But one study that really jumped out to our team here was looking at percent improvement in healthy older people and healthy younger people. So there was a study that did a six week aerobic exercise. They use cycling training program to assess changes in Vo two max, oxygen consumption, of course, workload and endurance.

Now, in the older group, these people averaged 80 years of age. In the younger group, the people averaged 24 years of age. Couldn't be further apart. And yet in both groups, there was about a 13% improvement in Vo two max, a 34% improvement in maximal workload. So that's basically how many watts could you hit?

And then a 2.4 fold improvement in endurance capacity. I found this staggering and I would not have predicted this prior to seeing this study. Now, of course, I want people to understand that the absolute levels of all of these things were significantly higher in the 24 year olds. That's a given. They put out more watts, they have a higher Vo two max, etcetera.

What we're talking about here is the malleability of the system. What we're talking about here is how much could individuals improve in six weeks? And the answer is they both improved dramatically. And I should point out something else. This particular study followed the six week training cycle that I just described with an eight week deconditioning period.

And what's worth pointing out here is that the older group declined much faster than the younger group. So both groups were able to see significant gains. But the older you were, the quicker you lost those gains with inactivity. Yeah. And so that speaks to what you mentioned earlier, which is the consistency.

Nick
So if someone starts and they do something for three months and they don't enjoy it, and so they drop off again, its not like theyre just going to stay at that level. That level is going to drop back down. And so being consistent is almost more important than how high you start. Thats right. You cant overstate this analogy of compounding.

Peter Attia
If anybody really just wants to understand how compounding works, just pull open excel and build a very simple formula that shows what happens if something compounds at 2% per month or 1% per month or something like that. I mean, it becomes so non linear, our brains can't comprehend that. And of course, I'm not suggesting that the gains in exercise will compound at that intensity, but the idea of how much fitter you can be after years of doing something. This is another point I want to make, which is, if you look at a lot of the literature in Vo two max training, you know, it suggests that people are capable of improving their Vo two max by 13%. Like that study I just quoted, a lot of people hear that and they look at the table that I showed earlier and they say, well, I just had my Vo two max tested and I was at the 50th percentile.

Theres no way Im going to get to the top 2% of someone two decades younger. That would require literally increasing my Vo two max by 80%. And this study showed that it could only happen 13%, to which I say, yeah, that study was six weeks long. When we give our patients these audacious goals, we talk about these as two and three year goals. So it's very important to understand that whatever we're talking about here, we're talking about over a very long period of time.

Nick
Well, I was going to say, too, with that long game on Vo two Max, as we saw earlier, that elite category also drops. So if you're 40, it's not like your elite category is the same when you're 70. So if you are making that progress and you are increasing just as you age, the categories are also going to decrease. So you're just naturally going to move up as long as you're maintaining. So its an interesting way to think about it.

Peter Attia
I have all of these crazy goals, as you know, and one of them is like, whats the oldest I can be such that my Vo two max in milliliters per kilogram per minute exceeds my age. Clearly, at some point that will cease to be true. Theres no 80 year old whose Vo two max is 80. So the question is like, where does that happen? And I think thats a really great heuristic for the health of a person is, does that happen when you're 30?

You hope not. If a 30 year old's Vo two max falls below 30, there's a huge problem. Does it happen when you're 40? That's probably where it happens for most people. Can you push that to 50?

Can you push that to 60? So, again, the only way to start to play that game is to basically get in shape and stay in shape. So on that, let's look at cardio training first and say, how would you put someone on a program to help. On the cardio side, once weve established that a person has the basics, theyre not immediately injured. Theyve got the ability to start doing some cardio training.

I like to really start with base building. Even for someone like me who trains a lot. Remember, 80% of my training volume is at zone two. Only 20% of my training volume is in that Vo two max range. And again, I've said this before, but it's always worth reiterating.

Understand that I am not training for anything other than the sport of life. If I were still training to be an athlete, if I were still training to be a cyclist, I would have to do something very different than what I'm stating. What I'm stating is far less intensive than someone who's trying to be a master's level athlete in pick your endurance sport. So now we're talking about a person who's new to this. What are we going to do?

I would be really happy if I could get them to start two days a week, 30 minutes a time. If I took a person who is relatively fit and we did two times a week at 30 minutes per session, they're not going to improve enough. They're going to experience no improvement. If I reduced my training volume to that level, I would probably go backwards. But you have to remember, when you're starting with a person who's very deconditioned, they will actually see a training benefit at such low volume.

So not going to throw them in three hour, four hour week training. We're going to start them much lower. Now, the question I get asked all the time is how do you help that individual calculate where their zone two is? And this is worth spending some time on. Again, for folks who want a bit of a primer, when we talk about zone two, we are not talking about the same zone two that shows up on your polar heart rate or your apple Watch or whatever other device you're talking about.

Were talking about a very specific mitochondrial level of zone two. And its referring to the highest level of work that you can do while keeping lactate at effectively an indefinite, steady state, which for most people tends to be below two millimole. So once youre exercising and lactate gets above two, youre probably not going to be able to sustain that for a couple of hours, which is effectively what we're talking about here, because metabolically you are going to move to an area where you're generating too much hydrogen along with too much lactate and the muscles are going to be compromised. So if you really want the gold standard for measuring zone two, you got to be kind of checking lactate levels. And I don't really advocate that for people, especially if they're starting out, I do it, but I'm probably an outlier here because I enjoy that level of precision.

So what I do recommend is two ways to be thinking about this. The first is on the rate of perceived exertion, which ive talked about at length in the past. And that is the talk test. Ive even posted a video, I think, somewhere that we can probably link to in the show notes, showing people what I look like when Im in zone two, and what my difficulty in speaking is. Well, link to that so people understand.

But because I know that people really like a little more guidance than that, I think using Phil Maffetone's map formula, maximum aerobic performance, I think, is what map stands for. But it's 180 minus your age is a target heart rate. And then if you're really new to the thing, which, again, is the audience we're now talking about, you might even subtract ten from that. So a 60 year old is going to potentially be as low as 110 beats per minute at a target. And as they get fitter, that's probably going to go a little bit higher.

Now, I want to point out that you don't want to be too wed to this as you get more and more involved in your training, because the fitter you get, I think the more variability you'll experience based on recovery. So my Maffetone formula would have my heart rate be 129. Okay, well, I can tell you 129 is never in zone two for me, except on the worst day, maybe once every two months, I might have a zone two based on lactate, where my actual heart rate ends up being 129. It's almost always going to be in the high one hundred thirty s and sometimes in the low 140s. So as you get more conditioned, the formula may be less and less valuable, and you will rely more and more on RPE.

Or if you really want to take it to the next level, you might even start using lactate. Final point, I say on this, even if a person is deconditioned, we will not use lactate on them, because an individual that's coming in who's metabolically unhealthy tends to have very high resting lactates. In fact, there were people walking around with a lactate of two millimole at rest. Clearly, in that person, using lactate provides no value, and you should rely on heart rate and RPe in that person. Let's say they're doing two days a week, 30 minutes a day.

Nick
How long do you like to see that consistency before you slowly increase either the duration or the number of days? In part, it comes down to what we talked about, which is, how do they feel? I almost want to inspire within them an appetite to do a little bit more. I mean, this sounds silly, but when you're starting out some of this stuff, a lot of it is just the growing pains of being able to sit on a bike and your butt doesn't hurt, or being able to walk on a treadmill and making sure that their knees aren't aching or things like that. I would say within eight weeks to twelve weeks, I would want to start pushing frequency and or duration, and I don't think there's a right answer here, and if there is, I'm sure someone will comment.

Peter Attia
I like to push frequency before I push duration, so I'd almost rather go from two to three to four sessions at 30 minutes before we start going to 45. But eventually I'm going to want the sessions to be at least 45 minutes each. On the other side of cardiorespiratory, vo two max. Before we get into how you start to build that in for people, we do have a few other graphs here that I think are insanely helpful in looking at why vo two max is so important as people age and so ill. Pull them up here.

Nick
But do you want to kind of talk viewers and listeners through this side of it as well? Yeah, this was a graph that I was able to get into the book. I fought hard for this one because, boy, nobody wanted this one in a book, and I can understand why it requires some explanation. So this is a figure that shows the hazard ratio of various comorbidities and performance subgroups. So again, what's a hazard ratio?

Peter Attia
Well, it gives you an estimate of relative risk. So let's start with the comorbidities, because I think that's easier to understand. So if a person is a smoker, are they at increased risk? And in this case, the risk is all cause mortality. Are they at an increased risk of death from all causes?

I think anybody would understand the answer. That question is obviously yes. The question is how much? And in this analysis, if you compare a smoker to a non smoker and ask the question, what is the probability of that smoker dying in the coming twelve months from any and all causes? The answer is, it's 41% greater than the non smoker.

Kind of makes sense. What if you take two people, one with coronary artery disease, known cad, and the other without? Well, that's about a 29% difference in all cause mortality, 29% greater risk, I should say, if I'm going to be more accurate. What about somebody with type two diabetes? Well, again, it's a 40% greater risk of all cause mortality in the coming year.

High blood pressure, 21%, end stage renal disease. So somebody who's on dialysis awaiting kidney transplant, a whopping 178% increase in all cause mortality. So now what we do is we do the same mortality analysis on that massive cohort of people for whom we have vo two maximum data. So these are the data that we showed earlier where we looked at people in those quartiles. And so what I do every time I run a patient through their vo two max the first time is I figure out where they are and say somebody shows up in the below average camp.

So that means theyre in the 25th to 50th percentile for their age. I say, look, if you just go from below average to above average, right? If I were just to compare you from your level at the 25th to 50th percentile to someone who's in the 50th to 75th percentile, the hazard ratio is 1.41. In other words, you are 41% more likely to die in the coming year than somebody who is that much fitter than you. And by the way, it's not lost on anybody that that's the exact same hazard ratio of a smoker to a non smoker.

That's how big the difference is. And if you want to go from below average to high, so now you're going from, say, the second quartile to the third quartile. It's a 100% difference in risk. It's a doubling of the risk of death for that coming decade. I won't go through the rest of these numbers here, but they're all staggering.

And by the way, even just going high to elite, 29% difference in relative risk. When I talk about how Vo two max is the single most important biomarker we have for lifespan, these are the data from which I make that claim. There are obviously other data that are identical to this on different cohorts, but the point is, there aren't other biomarkers that will give you hazard ratios of this magnitude. Now, people often ask, why is that the case? And I think the answer is that Vo two max is probably a remarkable integrator of work.

So it is not a biomarker that changes quickly and easily to the magnitudes required to do this. You're not going to take your Vo two max from low to elite in a year. You can do it. I would argue you absolutely can do it, but it's not going to happen. In a year.

And therefore, when it happens, it's going to reflect an astronomical volume of work that has been done. And the benefits of that work are what are being captured in the Vo two max number. Preston, that's kind of the lifespan side. I'm going to pull up the other graph here, which is more so on the healthspan side. And I think this was also in your book, but when you kind of combine all three of these Bo two max figures, the first one we looked at with just the bracket and the breakdown, how it compares to different diseases, and then this one kind of paints a really good holistic picture.

Nick
And so do you want to walk listeners, viewers through this as well? Yeah, this is another figure that we show our patients all the time. Actually, we're probably building another one of this, because there's a couple issues I have with this figure. Namely, it stops at the age of 75. So I want to see this data extended to another two decades.

Peter Attia
And I realize that it's harder and harder to get those data, but I think we can estimate them. What this figure shows is really the other bookend of why we want a high vo two max. So the figure above and the discussion I just had a moment ago makes it abundantly clear that if you want to live a long life, you better have a high vo two max. This figure says, if you want to live a good life, you better have a high vo two max. Because this gives you a very clear all in one view of what actually happens.

As your vo two max declines, you lose capacity. So the graph has a lot of information on here, but it can basically be distilled down into the following. You have three curves for the purpose of illustration. You have people in the top 5%, people right at the middle of the pack, and in the bottom 5%. So those are the green, black, and red curves, respectively.

By the way, for anybody paying attention, these data are pulled from a different data source than the previous data. I don't think this is as rigorous a data set, and therefore the numbers don't line up completely. So the 50th percentile here is not the 50th percentile elsewhere, but for the purpose of illustration, not important. The x axis is time, of course. So as age marches along, you are watching a reduction in vo two max, which is the y axis for all curves.

So again, observation number one is. Doesnt matter how fit you are, your vo two max is going down, down, down again. As I said, the problem with this graph, at least one of the problems, is stops at the age of 75. And unfortunately, that deprives a patient from seeing that the curve doesnt continue along the trajectory of what came before it. It actually gets steeper.

And so what you realize pretty quickly is that depending on where you want to be, and that's demonstrated by the activities on the right, you're going to need to be pretty high to avoid the fall. So what it's showing you is, hey, if you want to be able to run 10 miles an hour on flat ground, you need a vo two max in the mid to high fifties. If you want to be able to run 6 miles an hour, which is a ten minute mile up a very steep hill, you need to have a Vo two max of 50. And as you walk down this list, you see that the Vo two max requirement goes down as the aspiration goes down. The point that isn't really clear on this curve is at what point does the Vo two max become sort of rate limiting for activities of daily living?

And that's in the high teens, approximately. So once the Vo two max is into the high teens, we would say that you are now going to be limited in what you can do from an activity of daily living standpoint. Having studied these types of data for a very long time, I know that for myself personally, and by the way, this tends to be true for most of our patients when we put them through the centenarian decathlon exercise. Most people, at least based on what theyre telling you they want to be able to do in the last decade of their life, are going to require a Vo two max of about 30. So high twenties to 30 in the final decade of their life.

And I mean, Nick, when you look at that, what's your takeaway? If I'm telling you you need a Vo two max of 30 if you're 90, yeah. You better be in the 95th percentile and above along the way. You have to be higher, right? Because the people on this graph who have a Vo two max of 30 at age 75 are going to be lower than that at the age of 90.

So yet you have to be way above the top of the green curve at the outset. So, again, I know people hear me say, and you've alluded to this, that, oh, Peter, he's just being kind of extreme, blah, blah, blah, blah. No, no, no. I'm not being extreme. The data are right in front of us here.

If you want to be able to be completely unencumbered in the last decade of your life, you need to have a very high level of fitness when you're in midlife, and if you don't, that's okay. You have time to do it, but don't wait too long. Yeah, it kind of is one of those things where it's like we often joke, does everyone need to measure their lactate two times every workout? Probably not. That might be you on, like, the heavy data side, but looking at Vo two max, if you want to be able to do those things, that's not like you're measuring lactate every day.

Nick
That's just a black and white fact kind of written in stone. Yep. We should talk about how you can train for Vo two Max. But, yeah, you don't need the devices to do this, even though I like. Using devices well, and that's actually where we're going next.

Which is when do you start? When someone is starting to train or getting back into it. You mentioned you'll start them in the zone two a few days a week. Obviously, zone two two days a week, 30 minutes, is a lot different than a Vo two max exercise, which can take a lot more. So how do you have your patients in that age bracket, 50 and plus, when do you have them start training for Vo two max?

How do you have them start training? How do you think about that? So a couple things. One, the wider the base, the higher the peak. So I want to build a reasonable aerobic base before I start pushing Vo two max.

Peter Attia
And by the way, you do experience increases in Vo two max just from base building aerobic activity. So if you take a person who's completely deconditioned and you put them into just a zone two program, and you slowly add duration and frequency to that, and then you retest their Vo two max, it'll be higher, even if they have never done a single interval. But ultimately, to really start, to boost vo two max, you are going to need to add more intense movement. I think that the easiest way to do that and the way we typically do it with our patients in a really de trained individual or untrained individual, is just to add a little bit of interval training to the zone two workout. So, for example, if a person is doing their zone two on a treadmill, and let's say you've got them walking 3 miles an hour, and after a few months, they can handle 3 miles an hour at 4% or 5% incline, you say, great, I want you to finish the workout doing five 1 minute quote unquote bursts, where you increase the slope from 5% to 10%, and you're just going to do it for a minute, it's going to really tire them out.

You do a minute on and take a minute off. A minute on, take a minute off. So you start to get them used to increasing the intensity. This also becomes a chance to assess, is this going to be something they can do safely, or are they going to completely deteriorate in form? I'll give you an example of something I used to do.

So I used to do really, really what I think is, looking back, I'm lucky I never got injured. But I used to do some really stupid things for vo two max training that I think put me at too great a risk for injury to do deadlift Tabatas. So, you know, I would put 225 pounds on a bar and see how many reps I could do in 20 seconds, take 10 seconds off and repeat that eight times. Now, did that do a lot for my vo two max? Oh, you can bet it did.

But when I think about the risk I was putting myself under from a movement perspective, being under that much fatigue in the 7th and 8th round of that, where you're trying to push harder and harder, I just dont think that makes any sense. I mean, that doesnt make sense in someone like me who has a lot of training background. So what do I want to do? I want to make sure that theyre doing these intervals which well talk about in a second, in an activity where the form isnt going to deteriorate to the point of injury. Now, lets talk about the gold standard for how to train vo two max.

And this is something weve discussed at length in at least two or three other podcasts that well link to these sweet spots for that energy system is three to eight minutes of work. What defines that? What defines that is you do as much work as you can at a steady state in that period of time. So at the low end of that is three minutes. So, meaning how hard can you push for three minutes such that it's roughly the same level of work output?

So Watts, if you're on a bike, for example, but by the end of three minutes, you're truly spent. And then at the upper end of that, it would be up to eight minutes long, which obviously means it's going to be far less wattage, but the same physiologic response, which is by the end of it, you are truly gassed. I've talked about this again, I personally just tend to gravitate to four minutes. Four to five minutes is where I like to do the work. But I think it's great to mix it up and I'll use four minutes as an example just so folks understand what this should feel like.

When I'm doing a four minute interval, I barely noticed the first minute. So if at the end of the first minute of a four minute interval, youre dying, you went out way too hard, its okay. Try it the next time. At two minutes, Im still feeling pretty darn good. And believe it or not, sometimes Im wondering if I shouldnt be pushing a little bit harder.

At three minutes, Im truly wearing it. And that last minute is brutal. And thats again, assuming Im largely holding power constant for the four minutes. So that's a general rule. The way I describe it is three quarters of the way into the interval.

So six minutes if it's an eight minute interval, three minutes if it's a formative three quarters of the way into the interval, you should be at the 50% level of your pain. So once a person is ready to graduate into a dedicated vo two max session, that's what I want to do and I want to see them doing that once a week. Again, if you're training to be an elite level cyclist, you're going to have to do it more than that. But if youre training to just minimize risk and maximize gain, I want to see people start to push those. And maybe the first time they do it, they can only do four rounds of that.

But eventually youll get up to 5678 rounds of that. Again, if were talking about four minutes and when you put in a warmup and a cool down, and obviously I should say youre doing that at a one to one work to recovery ratio. I should have mentioned that earlier. So if its four minutes of work, its four minutes of very, very passive recovery, not a hardcore active recovery. It's a true rest and recovery.

We're talking about 60 to 75 minutes workouts here. Yeah. And so I think for what I'm hearing you say is correct, it's one of those as it relates to vo two max, even though it's so important, and we just looked at all the numbers of why it's so important. It's also one of those in an older population who maybe is deconditioned. You're not pushing them to start vo two max training right away.

Nick
Like it's important to get the base and it's also important to take even and when they start vo two max training, take it slow. And it's more important to build that over time than it is to just try to rush into it and either not enjoy it or worst case get hurt. That's right. And the older and less conditioned you are, the less I want you to hurt. During those vo two max intervals, I bring it back to me because I can speak from my own experience with much more clarity.

Peter Attia
The level of pain I am in today when I do my vo two max sets is nothing compared to what it was ten years ago. Nick, ten years ago, it was truly pushing to the point of vomiting. I do not push that hard anymore. I still push hard, probably harder than most people would expect, but it's not that level. And in ten years, when I'm in my early sixties, it will be even less of a push than it is today.

So the name of the game is play the game and stay in the game forever. And so we are really looking to minimize injury here, and we're looking to minimize burnout. And the first few times a person even experiments and dabbles with these four minute intervals, I actually want them to come away thinking, that wasn't too bad. Great. Try a little bit harder the next time.

But we're not here to sort of wipe you out after the first session or even the first couple of rounds. Anything else you want to say on the cardio side? Before we move to the strength side. We could talk about how to go about doing it. The good news is, for vo two max, I think you have many more options for zone two.

Believe it or not, you're kind of limited because of the steady state nature of it. So, again, for me, zone two, if I'm not traveling, is always on my bike, which is on a stationary bike, so on a trainer, and that's it. Full stop. If I'm traveling, I will usually do it on an inclined treadmill. So I go to what I consider a normal brisk walking speed, which is 3.4 to 3.5.

Then I just take the incline up. So I might warm up at ten degrees or 10% grade, but usually I wind up at about 15% grade. So three and a half miles an hour, 15% grade. That's my zone two. So outside of that, you can do it on a rowing machine if you're a really good rower.

But for most people, they're not efficient enough on a rowing machine, so that you typically end up blowing up and through their zone two ceiling. I can do it on a stairmaster, but, you know, I just have to be sort of careful about it. By the way, when you're using stairmasters and treadmills and all these things, remember, you probably don't want to have your hands on the device because there's too much variability in how much of the stress you're taking away. Does that make sense? Like if you're on a treadmill and you're holding onto it, there's so much variability in how much of the load you're alleviating that I prefer to just go hands off the machine and settle in at a steady state that's going to be consistent.

When it comes to vo two max, you have way more optionality. That's where I ride my bike outside. But you could be doing almost anything provided that there's a constant enough space for you to do it for at least three minutes. Swimming. Great way to do vo two max training because you don't have the impact, all those other things.

So you could do it on a treadmill if you wanted to and you could run or you could again just walk at a steeper incline if your zones permitted. So I guess thats the only other point I would make about this. And if someone is older, lets say 65 plus, so theyre in the older side of what were talking about and they havent done zone two before and they say hey, do you have a preference on, is it better to start on a treadmill versus a bike? Have you noticed anything as it relates to those two where its. We talked early on about the importance of even just walking, getting like 5000 steps, 7000 steps.

Nick
So would you want to see people or encourage them to start on a treadmill or do you think a bike is just as safe, just as effective? Yeah, I mean look, I think all things equal, if this is the only exercise a person is going to be doing, I might lean a little bit towards the treadmill if they were truly agnostic. Just because at the end of the day walking is a more valuable skill than cycling. Cycling has no application beyond cycling, whereas walking is a very important part of who we are. It's our superpower to be bipedal.

Peter Attia
So the more time you can spend doing it, the better you are. Again, for someone like me it's kind of moot because I walk a lot anyway. I'm rucking, I'm forcing that system to work elsewhere. So, you know, I might as well do something I enjoy the most, which is probably riding a bike. Moving on now from the cardio side to the strength side, we already kind of looked at how muscle mass can drop as we age.

Nick
What do we know about the possibility to gain muscle mass as we age? Doctor Justin? You know its really interesting, its not that dissimilar from what weve talked about on the cardio front. So research is very consistent here in demonstrating that resistance training can increase muscle strength and muscle hypertrophy at any age. Again, you tend to get into very small studies here, but when you look at large pooled analyses, you can see that even if you limit your analysis to people over the age of 80, which are people who are clearly in that area of being on the downhill for strength and hypertrophy training can offset losses and in a deconditioned individual can actually make gains.

Peter Attia
Just as I hopefully made a case for why you cant overstate the importance of cardio training both at low and high intensity, I dont think you can overstate the importance of strength training. I just dont think theres anybody out there who shouldnt be lifting weights. I cant think of a case, I mean, unless youre decidedly saying I dont want to live the longest, healthiest life, I can. If thats the case, then by all means dont lift weights. But if youre in the camp that says I want to maximize how well I can live and maybe even how long I can live, what should I do?

You have to be lifting weights regardless of age, regardless of sex, regardless of injury, you have to work around all of those things. So again, there's a very similar study to the one I cited earlier. Again, I don't want to go too study heavy, but this is just so illustrative of the point. There was a study that looked at people in their late seventies and early eighties and people in their twenties, and it at the outset measured three rep max for leg extension and then put them on a six week resistance training program. And the people in their late seventies and early eighties had a 78% increase in their strength, which is almost identical to the 83 84% increase that was found in the younger individuals.

Again, it's important to understand that, yes, these people were significantly different in the absolute strength that they had. The average leg extension in the people who were in their late seventies and early eighties was only 22 kg, versus 178 kg for the young participants. But nevertheless, this is an important point. That is, everybody has the capacity to improve and therefore everybody needs to be doing this. I think the other thing that we've talked about in previous podcasts, most notably, I think we've talked about this with Andy Galpin on a couple of occasions, is the importance of type two fibers.

One of the things that Andy said that has always stuck with me, and I think it's just such a great way to think about this. He almost described it as a hallmark of aging is the atrophy of the type two muscle fibers. So again, you have type one fibers, you have type two fibers. The type two fibers are the glycolytic fibers. They are the much more powerful fibers.

They have more contractile force. Theyre the ones that are responsible for power, not just muscle size and not even just strength and clearly not muscular endurance. And these are the things that basically peak when were in our twenties. And so every day im sort of thinking about what am I doing to preserve them and minimize their loss? And again, a study well link to demonstrates that type two muscle fiber cross sectional area was increased by 27% in men aged 60 to 73 with 13 weeks of resistance training.

Now, again, you have to train relatively heavy for your level of strength. You have to push to make those results happen. But again, this can be done very safely, as we'll talk about. Yeah, and I think now's the time to kind of look at that a little bit, which is you have a patient who's older, they come to you and they have not been strength training. Maybe they even do a Dexa.

Nick
And they see their metrics are really low as it relates to muscle mass. How do you start to incorporate that strength and resistance training to that individual? I mean, I think theres a real parallel here with what we talked about on the endurance side. So I always start from the same vantage point, which is if youre new to strength training, I want to make sure that in two to three months, youre looking back at the last two to three months thinking, a, I enjoyed that wasn't as bad as I thought it was, because remember, if someone hasn't lifted weights before, there's a reason, right? Like there's something about it that they are either intimidated by, afraid of, or didn't think it was valuable enough.

Peter Attia
I mean, there's a reason for it. So a, I want to undo that reason. Secondly, I want them to feel something is different. I want them to feel like, well, you know, I remember when I started this, I could only do this many pushups, and now I can do that many push ups. Or when I was doing leg extensions or leg presses, I had the pin on this weight and now it's like 50% higher.

That's the first principle. Second principle is, again, similarly, we are going to start with volume more than we are going to start with load. Muscular resistance matters more to me than strength at this point. So I'm not going to lead in with, let's go after those type two fibers it's going to be, let's work on the type one fibers, and I don't care if you need to do 15 to 20 reps on every exercise, so be it. I'm not even really at this point going to be concerned with all the nuances of RPE.

We've talked about this on many podcasts, including not just the podcast with Andy, but with Lane Norton. The data are that the number of reps you do for hypertrophy and strength, especially for hypertrophy, don't really matter, provided you get to within one or two reps of failure. We're not even really going to push that out of the gate. We might prescribe, hey, pick a weight that you fail at about twelve to 15 reps, but again, less concerned as to whether that's an RPE two or an RPE four. The other thing to keep in mind is in parallel to this, you've got to be working on some of the stability stuff, which is not necessarily weight based.

So this is where you're working on intra abdominal pressure exercises, really making sure that they can kind of pressurize the cylinder as we stay breathing exercises. So a lot of the stuff we borrow from DNS and PRI, we want to make sure that they can move their ribs correctly. And obviously, you want to make sure that they have the ability to even recruit muscles correctly. And a lot of those things are kind of hard. But I'll never forget an example.

Beth Lewis had me do one of the early times when I met her, which was laying on a floor. So picture me laying on my back. My knees are up, but my feet are flat on the ground. So I'm in a very relaxed position. And it was an exercise around being able to sequentially recruit hamstrings one leg at a time and put the foot down into the ground and pull it back, if that makes sense.

So again, that's a pure hamstring isolation exercise. And yet, despite having very strong hamstrings, I really struggled to do that exercise while keeping my pelvic floor stable. So again, those are the types of things where you're not going to get injured, but you're going to have to learn to start recruiting and controlling a muscle. And again, once you do that, youre much safer lifting. How do you think about resistance training for people who are in the even older category, which is, lets say 65 plus?

Nick
I know at the outset you kind of mentioned that at a certain point the muscle mass youre losing and the things you have to be aware of is even higher. So how do you talk to a patient about this who is even in that older category? I think you just have to do everything a lot slower. So, for example, somebody at this age, you'll do TRX, but you want to be much more stable in the positions you're doing. I would almost without exception, only have somebody at this age if they've never lifted before, only using machines to start.

Peter Attia
I wouldn't really want them mucking around too much with dumbbells outside of maybe doing carries. I wouldn't want them picking up dumbbells to do lunges or things like that. I would sort of save that for phase two of what they're doing. And truthfully, even though DNS, dynamic neuromuscular stabilization, which people know I'm a big fan of, when people think about it, you sort of think of these baby positions. Well, the reality of it is those positions are very important for people of any age.

And so teaching an older person, especially a person who's new to physical activity, some of those positions is very valuable because, a, it's doing all the stuff I talked about a second ago, but they're also getting comfortable with being on the floor and moving on the floor again, this is something that you and I will take for granted, Nick, for some time. But people 20 years older, 30 years older than us can't take it for granted that being on the floor, moving on the floor and getting up on the floor unassisted is something that they should be able to do easily. You kind of hinted at it there. So let's say someone is kind of in this older bracket, even 50 plus, and they're like, okay, I'm going to start resistance training. They obviously don't have a home gym.

Nick
Most people in that category aren't going to have that. And so if they do walk into kind of their local gym fitness center, you would encourage them to start on the machines at first and lower weights, just to slowly work that up before grabbing free weights, grabbing dumbbells, anything like that. At this level, it's difficult for me to provide very thorough analysis because everybody is different. And clearly what you might say makes sense if this person also happens to have a trainer who's really good with them. Yeah, you're going to say, look, you're going to push things a little bit quicker.

Peter Attia
But if we're really starting at, hey, this is a person who's going to be doing a lot of this stuff alone in a gym where there's a ton of intimidating stuff going around, I would say yeah, let's stick with the machines. And I wouldn't be trying to do dumbbell presses or kettlebell exercise or anything like that. No, I think you really want to build your strength and stability with body weight and with machines before you progress again. If you have the luxury of having a trainer and that trainer is very good, I think they'll be able to progress you more quickly to those other things. So then, Peter, you kind of hinted at it there, but a lot of people who are in the older category, they may be concerned about resistance training due to potential injury.

Nick
So when you have your patients who are older start to resistance train, start to build muscle, are you worried about injuries? Kind of. How do you speak to them about how they should think about that aspect, especially starting out or if theyve never started before? I think anybody whos worked with people, be it athletes or people who are really deconditioned, you always have to think about this, right, because youre always balancing, providing enough training stimulus to get the benefits. But, and remember, training is a hormetic activity.

Peter Attia
It has to create a stimulus, whether that be on the aerobic system, whether that be for type one fiber, the type two fiber. Like there has to be a stimulus that comes from pushing outside of a comfort zone. So we have to have that training stimulus. But we know that if we do too much we're going to get injured. And I hope that by now I've made the case for why injury must be avoided at all cost, because injury means time to decondition and the older we get, the more problematic that gets.

Again, I think about the back injury I sustained when I was 27 years old. That basically left me unable to walk for three months and unable to do much of anything for nine months. Well, today if you look at me, there's really no lasting effect of that. But imagine that had happened to me when I was 70. That's it.

My life is over. I never get back to where I was. So it's probably safe to say that the most common reason for injury when you're starting out is progressing along the intensity axis too soon. So remember we talked about how you push frequency, you can push duration, you could push intensity. I think you want to err on the side of my heuristic is move the frequency, then the duration, lastly the intensity.

So thats clearly true on the cardio training side, but I think its also true on the strength training side. Obviously, another very important part of injury is just a lack of neuromuscular control. So that accounts for many things from why people fall more frequently as they age to how people get injured. If were just limiting it to talking about strength training, why are individuals getting hurt when theyre lifting weights? Well, a lot of it is.

Maybe theyre moving a weight that they can't control. We've talked a lot about the importance of being able to control the eccentric phase of a movement. And I think we've all seen someone in the gym who's just throwing weights around and getting away with it. But you're going to stop getting away with that the older you get. So we want to really make sure that people have the coordination they're doing, the types of drills like agility ladders, hand eye coordination exercises, ball tosses, such that they're generating neuromuscular control in addition to strength.

Probably the other big area where we see injuries is due to a lack of movement variability. So people say, well, do I need to squat and deadlift and bench press? And I think the short answer is no. I think a lot of those things can be done with, for example, squats and deadlifts. You can accomplish many of those goals using single leg variants that are far less weight and even something like a bench press with a bar, I would much rather substitute in.

Once youre ready for that, floor presses and single arm floor presses, youll be laying on the floor with knees up, feet flat on the ground, one arm straight up, the other arm doing the presses. And again, whats nice about that is on a floor press, your range of motion is nowhere near what it is on a bench because youre obviously not going to be able to bring the elbow below your back, which you could on a bench. So you lose a bit of range. Its clearly not, quote unquote, as good a PeC exercise, but theres also a very good margin of safety there. Think about how much harder it is to hurt yourself doing a floor press than a regular traditional bench press.

These are just some slight examples of ways that you can think about minimizing injury. By the way, just as an example, like when I was coming back from shoulder surgery, I mean, it was probably a year of just doing floor presses before I proceeded to go back onto a bench. Yeah, it kind of reminded me, cant remember who it was, but someone once told us they used to do tabata deadlifts, and that could be a potential good example of a good way to get injured. Correct? I mean, anybody stupid enough to do that, Nick.

I mean, gosh, I just, I don't even know what I would say if. They'Re doing Tabata deadlifts, you have to question everything they say. Right? Like, how can they be trusted on anything? I think you would probably have to say they're, you shouldn't listen to a word they say.

Nick
Well, if I can remember who that is, I'll make sure to tune them out going forward. If you can remember, let us know on that front. Fall risks. You've talked about it before. You mentioned it earlier.

Do you just want to speak about fall risk? We also have a few graphs here that, again, we wouldn't have pulled if they didn't tell such a story. But I think it'd be really important here to talk about fall risk, because I think this is important not only for people in this age category, but also even anyone who's still listening that's even younger, to see what this can look like. And it's also to give them that motivation to even train at a younger age, kind of what you hinted at earlier. It's like saving for retirement at a much early age.

So what do you want to tell people about falls? I just don't think we can say enough about it. I think back to all of the failures of our traditional medical training, and there's so many, right? In four years and $250,000 of education at Stanford, how many hours of lecture did I have on exercise? That's zero.

Peter Attia
When was this discussion about falling presented to us as medical students? Never. So, in the United States, over 14 million, or 25% of people over the age of 65 will fall each year. Now, to be clear, that's people who report it. So we believe that that number is significantly higher.

This risk goes up quite non linearly. So by the time we're talking about octogenarians and nonagenarians, the annual incidence of falling is at least 50%. And you'll recall that I said that the risk of death from that fall, depending on the series you look at, will be somewhere between 15 and 30% of those falls, if they result in a broken hip, will result in fatality within the twelve months that ensue. Pull up this graph. This is a graph we had showed in a newsletter a couple of years ago.

Every once in a while, you dont really need any statistics to understand this. You just need to look at the graph. So this is the normalized death rate per 100,000 people over the last, basically 15 years. These are data from the CDC, and you can see that just from 2007 to 2016, weve seen a 30% increase in fall deaths. To put it in perspective, the projection is that by 2030, we're going to expect to see seven fall deaths every hour in the US.

Again, it's very difficult to wrap our minds around this. I think, and I think all of us as physicians, certainly myself in this category, unless you're a physician who specifically has a geriatric practice, maybe where you would see more of this. I just don't think we can wrap our minds around this problem and the magnitude of this problem. Again, if you look at the data in 2018, we're talking about 36 million falls reported to 8 million injuries. That looks like it's going to very quickly become 52 million falls with 12 million injuries in about five years for people over the age of 65.

So I think that it's safe to say that falls pose, not by magnitude but certainly by severity, as significant a threat to an aging individual as the typical horseman that we've spoken about so often. What do we know about the reasons for falls? What makes a fall worse than the others? Because, as you mentioned, these are only reported falls. So there's probably a lot of times where if someone falls and they get up and they're just a little banged up, they're not going to report it to anybody.

Nick
Well, if we want to double click on falling in particular, what do we know about more detail on that that make it more dangerous than others? Yeah. So I think there's two ways to kind of think about this. There's, what is it that increases our susceptibility to fall? Why is that going up as we age?

Peter Attia
And then there's another issue, which is not only does your probability of fall going up, but the severity of the fall is also going up as you age. So those two things are compounding. And thats why, if you look at the data, and I actually do think I included this figure in outlive, I have a figure that shows the death rate of falls by decade. And if youre trying to explain to somebody what exponential growth looks like, you just show them that graph. Thats exponential growth.

And thats why two things are compounding nonlinearly and you put them on top of each other. So lets talk about it. Why is this happening? Well, I think if youre asking why are there more falls, its going to be lower limb weakness. And we should double click on specifically the role of the toe there.

We had a recent podcast with Courtney Conley that discussed that difficulty with walking and balance. Remember, I said vestibular changes kick in around the age of 65. So all of us become less visually capable and we have less just innate vestibular capacity, visual difficulties, foot pain, poorly fitting footwear as we age. And then of course, theres medications that people take. So the older we get, the greater we see the incidence of hypertension.

Hypertension does need to be treated. Its an enormous risk for stroke and heart attack, but sometimes we over treat it and people become orthostatic. And when they stand up, they get lightheaded and fall. I dont know if you know anybody that thats happened to Nick, but that can also be kind of a devastating consequence of just being alive. You also talk about things that I dont think are necessarily age related.

All of those things are age related, but obviously just having uneven steps around clutter, all of those things play a role. So the more of these factors you check off, the more likely you are to fall. Now to the question of why is it more catastrophic? An amazing statistic is that the leading cause of traumatic brain injury in people over the age of 65 is falling. 95% of hip fractures are driven by falls.

Clearly, frailty is the leading cause of this. So frailty means poor muscle mass, poor reactivity, and low bone density. Those are probably the things that are driving the severity of the fall, which are so much higher in a person whos older than a person whos younger. You recall I alluded back to the podcast with Andy Galpin where we talked about the atrophy of the type two muscle fiber. Well, I think Andy used that as a great example of another reason why falls go up as people age is that if you or I step off a curb, we werent expecting to be there.

Or when youre stepping from one level to another and the level is different than you expected, that immediately destabilizes you. Well, the ability to react to that very quickly and get a firm footing, that is a very power driven movement. Thats not really about how strong you are. Its actually about how explosive and powerful you are. That is a type two muscle fiber phenomenon.

And as you watch the atrophy of those two fibers, you have far less reactive speed in your feet, and therefore you're more likely to fall in response to that. Again, the more we can train these systems, the better we are going to be able to resist falling. You mentioned there Courtney's episode, which if anyone hasn't listened to her watch, will be really good to go back to. But can we double click on the role that the foot plays in fall risk? And even in particular, one thing she talked about, which was toe strength.

Yeah, again, great episode. Absolutely worth going back to if you haven't listened to it. And also, we'll talk about the videos that Courtney and I put together. But foot health matters. And I think one of the things I took away from the discussion with Courtney was that toe strength was the biggest predictor of falling in people over 65.

In that podcast, Courtney ran me through a bunch of tests to determine toe strength. One of those tests, my two favorite, right. So one of those tests was a little card that you put under your toes. And it's a dynometer, so it measures the force that you can push each toe down as the card is trying to be pulled out. And so the rule of thumb, if I recall, was your great toe should be able to push down with at least 10% of your body weight.

And if it cant, its too weak, toes two through five collectively should be able to push down about 7% of your body weight. Another great test was the kind of lean forward test. So this was when youre standing up straight, we have this little laser device. It sounds more complicated than it is. Ive obviously already gone out and bought said laser on Amazon link to all that.

But you shoot it against a wall and you get a distance and then you lean forward and without catching yourself, just letting your toes basically do the work to see how far they support you. And you should be able to, I believe, be able to move at least five inches, or maybe it's four and a half inches there. So those are some great ways to test. And again, it's just added so much more to how I think about the importance of this stuff because I have to be honest with you, I've always thought of foot as an important thing. Not always, but, you know, in the past five years, the importance of toe strength and feet has been relevant to me for other reasons, but I never appreciated what a role it played in falling.

So I'll leave it at that. But just to say, we'll link here to a whole bunch of exercises that go to explain how to strengthen your toes. Next thing you want to talk about here is really calf strength. And again in the videos, Courtney goes through the benchmark tests for both gastroc and soleus test. I would say the following.

Virtually nobody I've ever seen has been able to pass these tests out of the gate. These are very difficult tests, and that tells us that most of us are heading into older age with underdeveloped strength in our lower leg. And so again, it's actually changed my training and I have added much more soleus and gastroc training. And frankly, its been at a much heavier weight than ive trained in the past because of my understanding of how those fibers work. The other thing here is around ankle mobility.

So another set of tests that Courtney put me through were around dorsiflexion and tibial rotation. And again, I was surprised that I did not pass these with flying colors. I think I passed on one side but not the other. We showed the side that I failed on, if my memory serves me correctly. Ill also always remember something that someone told me many years ago, which was, if you cant walk down a flight of normal height stairs, so call it a seven or eight inch step, whatever normal is, and keep your toes perfectly pointed forward, you dont have enough dorsiflexion.

So if you think about it, a lot of people, when theyre walking downstairs, have to turn their toes somewhat out to accommodate the tibial or the shin angle with the foot. And so I would encourage everybody the next time they're walking down stairs to actually see if they can walk with feet perfectly parallel and pointing forward. And if that's difficult on your lower shin and upper foot, you probably don't have enough dorsiflexion. And so again, we'll link here to a whole bunch of exercises that you can use to train that. And there are a handful of devices here that I use, and I really like these devices.

Don't have any affiliation with all of them. So not promoting something that I'm a part of, but definitely something that, that I'm a big fan of. The last few questions we wanted to hit are just kind of on a few different variables that relate to exercise. The first is bone mineral density, and you kind of talked about it with falls and frailty. And we had a whole AMA that people can look at on bone mineral density.

Nick
But. But what do we know about resistance training for bone mineral density in older adults? Because I do know this is something that as people get older, they're much more worried about and looking at, even compared to people in their twenties, thirties. And also, I think this allows you to talk about, which I think is one of your favorite news stories on this subject. So do you want to speak to that?

Peter Attia
Yeah. BMD or bone mineral density, which is one of the kind of four pieces of data you get from a Dexa scan, is typically reported as both a Z score and a T score. Now, it's really important if you are getting a Dexa scan because you want this information, you need to make sure that it's reported segmentally. So a lot of places that do a Dexa scan don't give you the hip and lumbar spine readings. They'll just give you total body T score and Z score.

And unfortunately, that is not sufficient to understand your risk. So you need a T score for the lumbar spine, and you need a T score for at least one, if not both, of the hips. We'd like to see it for both hips, but some places we'll just do one because the concordance between hips is pretty high. I'll take a moment just to explain what a T score is. A T score is the difference between your bone mineral density and the mean level for a 30 year old of your sex divided by the standard deviation.

If the T score is below minus one, that is defined as osteopenia. If the T score is below -2.5 that is defined as osteoporosis. So that's sort of one thing to understand. Another thing to understand is how bones work from a density standpoint. A lot of this is already covered in that AMA that we did, and we should absolutely link to that for long listening.

But I'm just kind of given the TLDR here. We basically are in a bone building, net bone building phase until our early twenties. We sort of hit bone peak, and then it's mostly a decline from that point on. For women, the decline becomes quite precipitous once they hit menopause if they are not placed on estrogen therapy. You might ask why.

Well, it has to do with the fact that estrogen is potentially the single most important hormone when it comes to regulating bone health. And the reason for it is that bones respond to load. So that gets to your question, Nick, which is, why does strength training matter so much? It's because it is a load. The bones need a compressive force on them to grow, and the compressive force comes typically when the muscles around them are contracting.

By the way, the one thing that I recall from that podcast that stood out as even a greater impact on bone strength was wrestling in jiu jitsu. Take that. For what it's worth. I know that both of those are near and dear to your heart, but what happens is when the bone is placed under load, think of it as a strain gauge that measures the deflection of the bone. And that strain gauge has to communicate through a chemical signal to the osteoblasts and osteoclasts, which are the bone building and bone decaying cells, respectively.

And that chemical signal. So the mechanical signal is transduced into a chemical signal that's done via estrogen. And so that's why estrogen is so important, because it's the chemical messenger that says, hey, I'm under load, I'm being deformed. Please give me more bone building material here. So what else can I say about that?

Well, look, unfortunately, this is another one of those things that declines precipitously with age, and it's nonlinear, meaning the rate of decline goes up by decade. It's not a constant rate of decline. You referred to a study that was done by Belinda Beck at, I believe, Griffith University in Australia. We'll link to that. But it was called the lift more trial.

It was published in 2015. I've linked many times before to a great YouTube video where she kind of talks about the high level of this. This is a study that recruited healthy postmenopausal women with low bone mass. So these were women that all had at least osteopenia t scores below minus one. And the intervention group was given eight months of just twice weekly, 30 minutes at a time.

So 60 minutes total, supervised strength training, where they were doing five sets of five reps at more than 85% of their one rep max. The reason this study always caught my attention is, is these were women who didn't have a background in strength training, and yet they were doing five by fives. And so we want to also kind of dismiss the idea that you can't take somebody who's new and get them strong. Five by fives are real set. Those are big workouts, and these are being pushed to 85% beyond 85% of their one rm.

So that was the intervention. The control group was just given low intensity exercise. And after eight months, the bmd of the lumbar spine in the treatment group had gone up by almost 3% at the same time that the controls had lost over 1% of the bmd in their lumbar spine. And basically the same thing was true in the femoral neck. You saw an increase in the women who had been training versus a significant, it was almost a 2% decrease in the control group group.

So, again, to me, its just one of my favorite studies because of the population that its using and the simplicity of the intervention. So I just cant say enough about the importance of this. I didnt realize it either. But how awesome of a name for a study is lift Moore. M o r, like its an a plus name.

Gotta do it, just gotta do it. That should be a license plate for you. I feel like every now and then youre looking for license plates, lift more is an a one. Although people might be expecting someone insanely jacked bodybuilder. That's true.

Nick
Arnold style to walk out of that. Yeah, I would not do justice to that license plate. Yeah, that's probably true. Just need to do more to bottom deadlifts to get that muscle size up. Okay, what about protein?

Another subject that you've talked heavily about, tons of places we can link to all of them. But how does protein relate to muscle building, especially in people 15 plus? And how do you talk to your patients about it? Oh, boy, they're sick of it, I'm sure, because we talk about it a lot. Protein by itself stimulates muscle protein synthesis.

Peter Attia
Ingested protein by itself stimulates muscle protein synthesis. So in English, what that means is simply eating protein, even without a training stimulus, promotes the building of muscle. Of course, that effect is dwarfed by the effect of a training stimulus plus protein. Look, I think at the high level, this is relatively straightforward. You probably want at least 1.6 grams of protein per kilogram of body weight.

And as you get older, you should start to move that number higher and higher because of what's called anabolic resistance. So as we get older, the muscles become less sensitive to the effects of the amino acids. By the way, I won't get into it here, because we covered it in great depth on the podcast recently with Luke von Loon, but it was actually the first time I had a really good explanation, at least speculation, as to why anabolic resistance is taking place. So I've never actually really known why. And it turns out that maybe that's because nobody knows.

But Luke offered a list of several very interesting and plausible physiologic reasons for why the aging individual is less and less sensitive to amino acids. So, again, we've done so much on protein, I don't think I need to say more here. We'll link to all of those references with both Luke and Don Layman and Lane Norton as well. But the long and short of it is, all of the stuff we're talking about in this podcast needs to be supported nutritionally, and nothing is more important than that of protein intake. We can talk about how to divide it all up, all of that's covered in those podcasts.

But the short of it is, you really want to be at a minimum of 20 grams per serving. But it's more nuanced than that, of course, because the type of protein determines the speed with which you're going to be able to incorporate it. General rule is protein in food is going to give you a longer, more forgiving window in which to assimilate it. We can link to even a recent newsletter we wrote that addressed a study looking at some of the conventional beliefs that were challenged by a study that actually Luke was an author on looking at the difference between whey and casein protein in terms of muscle protein synthesis over time. All right, so, Peter, I think that kind of wraps at least everything we were hoping to get out.

Nick
And as we said in the beginning, we've covered some of this stuff in greater detail in other places we'll link to. We didnt want to bog it down with too many scientific studies, and we hope it just kind of give people a little bit of insight, how to think about starting to exercise as an older age and one why its important, how to do it, how to start building it up. And so I think as we wrap, any last bit of insight or any last bit of advice you would give to people who are in that category, the 50 plus, the 65 plus, who are saying, okay, you convinced me, I'm going to start doing this. Yeah, I just kind of go back to some of the stuff we've already talked about, which is if you're in that camp, if I'm talking to you, and I've hopefully convinced you of this, I don't want you to get hurt. I want you to have fun.

Peter Attia
I want you to look back at this in 90 days and say, I'm really glad I made this change. And that means do something as much as you can. Try to do something every day. And if it means going out for a 15 minutes walk after dinner, great. If three months from now youve managed to get to a point where you have a portfolio approach to how youre exercising.

So youre doing a little bit of stuff that is actually resistance training, hopefully even progressing beyond body weight. And youre even starting to challenge the different energy systems from a cardio perspective, walking at a modest pace versus a little bit of really brisk walking or uphill walking. And you're not injured and you're enjoying it. We've won the game. Yeah, I think that's all really solid.

Nick
And hopefully, again, hopefully people enjoy this no matter what age you are. But I think that's it. Peter. So anything else you want to say before we part ways? Try to avoid Tabata deadlifts.

Just so you know, I didn't miss it. I did appreciate the callback to you face planning in Brazil from low blood pressure. So we'll include those links to the photos in the show notes, but I didn't want to interrupt you because you were going down a good path, but I did pick that up, just so you know. All right, awesome, Peter. We'll see you next time.

Peter Attia
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#307 - Exercise for aging people: where to begin, and how to minimize risk while maximizing potential | Peter Attia, M.D.

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1: Introduction to Exercise for Aging

2: Understanding the Pillars of Exercise

3: Strategies to Begin Exercising

4: Reducing Injury and Maximizing Outcomes

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