Outlive by Peter Attia Book Summary & Actionable Steps | YouTube Summarizer

Transcript

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Peter aa's outlive the science and art of longevity is split into three parts and that's how this book summary and review is divided as well critiques and action items at the end time stamps in the description as always and this video is dedicated to you Mom part one covers the way we approach medicine first we

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need to Define longevity it's not just a matter of how long you live which is your chronological lifespan but also how well you live meaning the quality of those years which we call Health span Health span is typically defined as the period of life where we are free from

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disability or disease but that's a bit of a low bar and what we're striving to do here is maintain and improve our physical and mental function rather than letting it deteriorate from the beginning of human time around 250,000 years ago or so until the first half of

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the 19th century we had medicine 1.0 based on observation and guesswork this is where we believe the importance of bodily humors gods and so on as the root causes of health and disease medicine 2.0 then arose in the mid 19th century

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and continues today which was largely a shift in the way we thought it was a paradigm shift and included things like germ Theory sanitation and antimicrobials Medicine 2.0 allowed us to double our life expectancy from around 35 to 40 to 70 to 80 it's

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impressive stuff prior to 1900 people died from Fast causes like accidents injuries and infectious diseases of various kinds much of the short life expectancy was also skewed due to how dangerous childb birth was was to the mother and the high infant mortality rates medicine 2.0 eradicated deadly

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diseases like polio small poox and now allows for curing heepsy with drugs amazing it's so effective that nowadays people are much more likely to die from slow causes these slow causes are what AA calls The Four Horsemen heart disease cancer neurodegenerative disease and

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metabolic dysfunction including type 2 diabetes much of medicine 2.0 is better suited to preventing fast death rather than slow death things like trauma and severe infections but far less effective at helping patients with chronic conditions like the four horsemen the prevalence of the horsemen diseases

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increases sharply with age but they begin much earlier than we recognize for example even if a heart attack can kill you suddenly the underlying disease process has been progressing in your coronary arteries for at least a couple decades therefore we need to step in sooner to prevent the horsemen from

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developing one of the biggest issues between medicine 2.0 and 3.0 is how type 2 diabetes and metabolic dysfunction is approached there are a few diagnostic C offs for type 2 diabetes such as a hemoglobin A1c of 6.5% or higher this measures how much glucose is stuck on

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the hemoglobin in your red blood cells and roughly estimates your average blood sugar over the last 3 months but if you're less than that say 6.4 or 6.3 you're in the pre-diabetic range as my mother has been for the last several years and the recommended treatment from

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medicine 2.0 is some vague lifestyle interventions meaning exercise and nutrition and possibly metformin plus annual monitoring to see if you develop diabetes there are multiple issues with this one of which is that people with pre-diabetes don't think they have metabolic dysfunction since hey they're

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pre-diabetic and not fully diabetic so everything must be fine right and this is what my mom actually believed for the longest time despite my pleas to the contrary and what this causes is a very casual approach to metabolic Health you don't only develop metabolic dysfunction when you have a hemoglobin A1c of 6.5 or

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higher it's a spectrum and you've been experiencing metabolic dysfunction well before meeting that cut off this is just the final stage of dysfunction it's not binary where either you have it or you don't but unfortunately with medicine 2.0 that's where we decide whether or not to intervene modern medicine is

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pretty crap at handling the chronic diseases of Aging that will kill most of us the partial good news is that each Horseman is cumulative the product of multiple risk factors adding up and compounding over time and many of these risk factors can be reduced or eliminated medicine 3 .0 is what AA and

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others have been pushing for which has two main Hallmarks first we want to prevent rather than treat chronic disease by acting early and aggressively and tailoring our therapies to the individual based on the best available evidence which by the way isn't always a randomized control trial and second

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Health span should be given just as much effort and attention as lifespan medicine 2.0 only really focused on lifespan one thing incredibly misunderstood by most people today including many Physicians is risk risk is not something to be avoided at all costs rather it's something we need to

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understand analyze and work with don't let risk be a reason to do nothing I have inflammatory bowel disease Crohn's disease ult colitis and a few years ago there was weak correlational data that show that vitamin D supplementation improved rates of remission for people with mind disease the study had several

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limitations and it wasn't clear if it was correlational or causational meaning if people who are healthier and in remission will be outside and active and therefore have higher vitamin D or if vitamin D supplementation can help with remission regardless with high quality supplements and reasonable dosing

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vitamin D supplementation has low risk and possibly a high upside my GI doctor felt otherwise in the last year another study came out demonstrating with stronger evidence that supplementation is in fact beneficial and more likely to be causational and not correlational I'm

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glad I didn't listen to my GI and made the risk informed decision instead many people are willing to take on any action without robust evidence and they don't understand asymmetric risk if the risk is small and the upside is large you should probably do it evidence-based medicine is what I was taught in the

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201s when I was in medical school and it has its place but being overly dogmatic and inflexible with research and data and not focusing on clinical judgment is the issue I see across many Physicians and social media personalities instead of evidencebased we need to shift to evidence informed actually I've talked

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about this before and if you want to be technical evidence-based by definition includes integrating the experience of the clinician the values of the patient and the best available scientific information to guide decision-making about clinical management but when uttered by most they mean RCT data or

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bust so we'll say evidence informed to make a better distinction randomized control trials are best at answering questions about simple interventions like vaccines or medications to lower cholesterol maybe across 1 or 5 years but for other interventions particularly

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those involving the strategies of longevity it's almost impossible living systems are messy and we need to be comfortable without having absolute certainty there are four main points to consider with medicine 3.0 first greater emphasis on prevention rather than treatment second considering each

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patient as a unique individual we're no longer evidence-based which has the issues such as the vitamin D story but now evidence informed three we take an honest assessment and acceptance of risk including the risk of doing nothing and four we focus on maintaining Health span the quality of life we all arguably care

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more about than lifespan to better understand our efforts and to put them into perspective we need to focus on our marginal decade our' 70s 8s '90s or beyond what do you want to be doing in your final decades what's the plan for the rest of your life a typical Modern

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Life Course looks like this as we get older our health span steadily declines with medicine 2.0 it steps in towards the end treating heart disease or cancer or whatever else prolonging your life by a few months to a few years if you're lucky but this occurs when your health span is already compromised medicine 3.0

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is the ideal line and trajectory when you do decline The Descent is steep but relatively brief this is called squaring the longevity curve many people make the mistake of focusing on tactics instead of strategy things like shortcuts what supplements to use and so on but we're

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going to apply a three-part approach to longevity objectives which leads to strategy which leads to tactics Health span is comprised of three categories cognitive decline physical body function and emotional health which is largely independent of age unlike the other two but keep in mind that lifespan and

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health span are not independent variables but rather tightly intertwined for example increasing your muscle strength and improving cardiorespiratory Fitness reduces your risk of dying from all causes by a far greater magnitude than you could do by taking whatever cocktail of medications with medicine

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3.0 we have a longevity tactics toolkit with five arms first is exercise which has the subcomponents of strength stability aerobic efficiency and Peak aerobic capacity second is nutrition then we have sleep fourth emotional health and fifth exogenous molecules

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meaning drugs hormones and supplements and there's also a bonus sixth bucket of radical temperature exposure accident exposure pollution and things like that in part two AA focuses on each of the four horsemen the key thing you'll find from centenarians those who live to 100 years and Beyond is that they live

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longer with good function and without chronic disease and with these chronic diseases a lot of them are intertwined medicine 2.0 looks at diseases as entirely separate from one another treating diabetes as if it was unrelated to cancer or Alzheimer's even though it's a risk factor for both out of the

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Four Horsemen let's start with metabolic dysfunction we have an epidemic of obesity and metabolic dysfunction but not everyone who is obese is metabolically unhealthy and not everyone who is metabolically unhealthy is obese metabolic syndrome is defined by five criteria but you need just three or more

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to have metabolic syndrome along with more than 30% of other Americans the five criteria are hypertension that's a blood pressure above 130 over 85 high triglycerides above 150 Meg per deciliter low HDL cholesterol which is lower than 40 in men or lower than 50 meges per decil in women Central

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adiposity meaning a waist circumference greater than 40 in in men or 35 in in women and fifth an elevated fasting blood glucose of 110 Mi per deciliter or higher having metabolic syndrome is associated with higher risk of heart disease stroke type 2 diabetes and other

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chronic illnesses lots of us are concerned with how much fat we have but where you store your fat is actually more important sub cutaneous fat the stuff just under your skin is largely for vanity but visceral fat the fat around your internal organs is linked to increased risk of cancer and

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cardiovascular disease since it secretes inflammatory cyto kindes Asians such as yours truly have less capacity to store subcutaneous fat than Caucasians before it starts going to visceral fat think of your subcutaneous fat stores as a bathtub and as it overflows additional

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fat starts overflowing into your visceral fat or on the floor of the bathroom in this analogy and we all have different sized bathtubs this is why when you've seen BMI zones for different ethnicities the overweight BMI for Asians is shifted to around 23 whereas Caucasians are 25 and the same

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with obesity which is defined as 27 for Asians and 30 for Caucasians AA has his patients undergo an annual dexa scan which precisely tells you your overall body fat including specifically how much is visceral versus subcutaneous I do a dexa scan once per year and if you're more on top of things maybe you'll do it

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twice per year it's the most accurate way to measure body composition visceral body fat and even muscle mass and it gives us this important metric called appendicular lean mass which we'll discuss more later in this video but the issue is that you're not going to do dexa scans regularly enough to see yourself trending a regular scale will

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tell you just your weight but you have no idea of knowing how much is muscle versus fat and subcutaneous versus visceral to get around this I use the wiing body scan scale which uses bioimpedance through not only your feet but also your hands to measure your body fat and also your visceral body fat it's

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of course not as accurate as a dexa scan meaning I can't trust the exact number it tells me but it is precise meaning if it goes up or down by 1% I can trust that my true figure per DEA scan would also go up or down by roughly that amount and I find that really valuable as my diet and exercise routine they're

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going to change multiple times between my annual dexa scans and I want to know if I'm on the right track or not use the code Kevin Bal 10 for 10% off the body scan for a limited time or use the link in the description diabetes is ranked as the seventh or eighth leading cause of death in the US but the actual figure is

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is much greater since we undercount its true impact as those with diabetes have much greater risk of cardiovascular disease cancer Alzheimer's and other dementias Peter tests patients in multiple ways to assess their metabolic function not only with dexas scans but also liver tests called as and ALT which

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tell you about your levels of liver inflammation and whether or not you have early stages of fatty liver disease but note that the recommended normal ranges that the lab gives you are higher than he would like since what is normal today is based on population percentiles and it's certainly not the same as healthy

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as our population has become more unhealthy over the decades he also looks at uric acid since higher levels promote fat storage but are also linked to high blood pressure and of course insulin and the way a patient responds to glucose namely with an oral glucose tolerance test this is where you drink a sugary

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solution and your blood is then drawn every 30 minutes for 2 hours to see how your insulin and glucose levels respond this is far more useful than simply a fasting blood sugar or your hemoglobin A1c next let's move to Heart disease which is the number one killer of Americans and is very widely

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misunderstood ironically American women are 10 times more likely to die from AOS scerotic disease than from breast cancer but we have pink ribbons everywhere for breast cancer that far outweigh the number of aha red ribbons for women's heart disease awareness let's talk cholesterol first there is no such thing

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as good or bad cholesterol and your total cholesterol isn't important either for your risk of heart disease cholesterol is lipid soluble so it doesn't dissolve in water or blood and therefore needs complex molecules called lipoproteins to transport it the different lipoproteins combined with the cholesterol are what makes it good or

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bad more or less dangerous HDL has more protein in relation to fat and is therefore more dense hence the name highdensity lipoprotein and LDL has more fat or lipids compared to protein hence low density each lipoprotein particle is wrapped by one or more large molecules

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called APO lipoproteins which provide structure stability and solubility to the particle hdls are wrapped in APO lipo protein a and LDL are wrapped in APO lipoprotein b or APO here's the key thing every single lipoprotein that contributes to atherosclerosis not just

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LDL but others too carries the APO protein signature that's because apoa particles like HDL can cross the lining inside your blood vessels the endothelium very easily in both directions but apob particles like LDL are more likely to get stuck when the

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LDL or vldl or other particle with that apob gets stuck in the wall and becomes oxidized that then kicks off the Cascade of atherosclerosis the process that ultimately clogs your arteries and causes heart attacks and strokes this is why rather than asking your doctor for your LDL you should ask them for your

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apob as this tells you the total number of all particles with apob including LDL but also vldl and others that are dangerous this is far more important and a better predictor of your cardiovascular risk so we know apob is bad but there's another version that's

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extra bad Ultra villainous called LP little a this lipoprotein is formed when an LDL particle is fused with another rarer protein called APO lipoprotein ltil a or APO a for short not to be confused with APO lipoprotein big a or APO a which makes up HDL particles APO

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little a wraps Loosely around LDL with multiple cringes that look like the Danish Pastry these are what make LP ltil a so dangerous as the particles pass through the bloodstream they scoop up bits of oxidized lipid molecules and carry them along these are even more likely than Reg LDL particles to get

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stuck in the blood vessel wall therefore in addition to apob you need to ask your doctor to check your LP little a as it is the most prevalent hereditary risk factor for heart disease and because it's largely genetic unlike the other cholesterol markers and metrics you only really need to test it once in your life

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so we know LP ltil a is part of your apob number but someone with a low apob can still have a dangerously High LP ltil a like I do because the potency and danger of these LP little a numbers can cause tremendous damage even even in small numbers the issue is that you

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can't really lower your LP little a as it's largely genetic unless you go to these new injectable drugs called pcsk K9 Inhibitors which lowers it by about 30% the issue with them is that they're very expensive about $500 per month out of pocket and insurance won't approve

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most people since their indications are stuck in medicine 2.0 you want to focus on lowering your apob which can be done with things like statins think of LP little a as modulating your risk so if you have a higher LP little a like I do then you want to aim for a lower apob Peter believes you can't lower your apob

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or LDL low enough just as long as you don't have side effects from the medications he doesn't pay much attention to HDL because while having a low HDL is associated with higher risk it isn't causal drugs that increase HDL have failed to reduce the risk of having cardiovascular events in clinical trials

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when it comes to diet about 1/3 to 1/ half of people who consume high amounts of saturated fats will see a dramatic increase in apob particles monounsaturated fats on the other hand like extra verion olive oil macadamia nuts avocados and so on don't have this effect so he pushes his patients to

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consume more of those about 50 to 60% of total fat intake it's not about limiting fats but shifting to fats that promote a better lipid profile what actually happens in your artery walls can be visualized with two types of CT scans you can get a calcium score which is lower resolution and only shows

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calcified lesions in your arteries or a CT angiogram which is a higher resolution test that identifies both calcified and soft plaques that proceed calcification when these plaques become unstable eroding or even erupting the damaged plaque can cause the formation of a clot which can block the blood

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vessel and lead to a heart attack or stroke I got my CT angiogram done last year to help me and my primary care doctor guide my treatment my LP little light is Skyhigh and my apob was lower to around 70 with drugs ideally we'd want to go lower on my apob given my

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high LP little a but more aggressive statins caus me to have insulin resistance which by the way I wouldn't have caught if it wasn't for my CGM which I'll tell you about later in this video with the CT angiogram showing nothing at all we felt comfortable hovering around 70 for the time being

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until we deem it necessary to switch to something like a pcsk9 inhibitor or bidic acid things that don't have those same metabolic side effects of certain statins and by the way the insulin resistance was pretty huge my average daily blood sugar went from low to mid90s to 110 to 115 range massive

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difference and a downside of stattin for some people muscle AES are another side effect other cholesterol lowering medications which you can think of as apob clearance increasers include the following first statins as we discussed which inhibit cholesterol synthesis and prompt the liver to increase the

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expression of LDL receptors taking more LDL out of blood circulation next aetam which blocks the absorption of cholesterol in the GI tract but this is the cholesterol you make and recycle via your liver and biliary system not the stuff you eat keep in mind the cholesterol you eat in food has no

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connection to the cholesterol in your blood the vast majority of the cholesterol in your circulation is produced by your own cells next bidic acid which is for people who can't tolerate statins its function is very similar but rather than inhibiting cholesterol synthesis everywhere in the body as statins do hence the muscle EGS

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for some people bidic acid only does so in the liver and PCs K9 Inhibitors which helps upregulate the number of LDL receptors by reducing their rate of degradation next let's talk cancer the second leading cause of death in the US right after heart disease the key is to detect and act early early to prevent it

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progressing to stages where we can't do much about it too often we detect it when it's causing other symptoms at which point it's usually too advanced to be removed or it's already metastasized meaning it's spread to other areas of the body it's a three-part strategy to deal with cancer first prevention second treatments targeting its weaknesses and

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third early detection you're going to find a theme Here of metabolic dysfunction linking to all the other horsemen and surprise surprise the link between obesity diabetes and cancer is primarily driven by metabolic dysfunction driv inflammation and more growth factors like insulin what I was

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taught in medical school is that because there are tons of false positives with broad screening we shouldn't do them on most people as this can result in more invasive procedures with risk like biopsies and emotional cost too for something that might be nothing this would require a whole discussion on biostatistics with sensitivity

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specificity positive predictive value negative predictive value and so on which is beyond the scope of this video but we do cover it quite in depth in our ultimate research course for Premed and Med students but in medicine 3.0 we say the tests are useful and there are many ways to make them more useful and accurate for example stack the test

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modalities you could incorporate ultrasound and MRI in addition to mamography when looking for breast cancer with multiple tests stacked on top of each other the resolution improves and fewer unnecessary procedures are performed the recommended age for colonoscopy screening used to be 50 repeated every 10 years but the

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American Cancer Society updated its guidelines in 2018 lowering the age to 45 for those with average risk obviously those with higher risk would get it done sooner and at a higher frequency like me I'm 33 and I've had six or seven Scopes by now since I have inflammatory bow

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disease and if you're concerned about having your first fear not I've done two Vlogs showing the experience linked up here and down below Atia being the overachiever likes his patient starting at 40 for those with normal risk and repeat it every 2 to 3 years which seems aggressive but it's Justified since

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Studies have shown colon cancer can appear 6 months to 2 years after a normal scope next we're on to dementia the most common form of which is Alzheimer's but also includes Louis body dementia Parkinson's and a handful of others what can you do to reduce your risk surprise surprise metabolic health

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comes up yet again in study after study especially if you have the apoe4 genotype which means you're at a higher risk for Alzheimer's genetically this becomes even more important the good news here is that exercise is the most powerful tool in the toolkit having a two-pronged approach on Alzheimer's

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first it helps maintain glucose control and second it improves the health of our vascular ature this is important when we look at the two theories of why Alzheimer's occurs in the first place the first theory is a gradual reduction in blood flow eventually creating a energy crisis for the neurons triggering

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a Cascade of events leading to neurod degeneration the second theory is abnormal glucose metabolism in the brain which makes sense since type 2 diabetes has a two to threefold increase in your risk of developing Alzheimer's just like reduced blood flow impaired glucose metabolism starves the neurons of energy

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and provokes a Cascade of responses leading to inflammation stress mitochondrial dysfunction and ultimately neurod degeneration there are other forms of prevention too the more Network and sub networks you've built up over your lifetime via education or experience or by developing complex

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skills like speaking a foreign language or playing a musical instrument the more resistant you are to cognitive decline the brain can continue functioning as some networks begin to fail due to what is called a cognitive Reserve there is a parallel concept known as movement Reserve in Parkinson's disease people

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with better movement patterns and a longer history of moving their bodies such as trained or frequent athletes tend to resist or slow their progression of the disease compared to sedentary people in terms of broad strategy we know the following first what's good for the heart is good for the brain in other

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words low apob low inflammation and low oxidative stress second what's good for the liver and pancreas is good for the brain again bringing up the conversation of metabolic Health three time is Key meaning work on prevention early and finally the most powerful tool is

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exercise exerise which acts in multiple ways both vascular and metabolic to preserve brain health in terms of tactical advice Sleep Quality is key here for lowering stress and cortisol protecting your hearing is important to reduce your risk of dementia possibly because those with hearing loss tend to

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pull back and withdraw from socializing intellectual stimulation and feeling connected brushing and flossing your teeth is critical to oral health which is tied to improved cardiovascular disease risk and doing a dry sauna protocol of four sessions per week about 20 minutes per session at 179°

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Fahrenheit or hotter shows benefits too finally part three is where AA focuses on exercise nutrition and emotional health if we go back to those five arms of the longevity toolkit from earlier exercise is actually the most potent domain for both Health span and lifespan AA devides exercise into four categories

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aerobic efficiency maximum aerobic output measured by your V2 max strength and stability while we had more concrete science for the four horsemen nutrition and exercise are much more complex with any new patient he evaluates the following are they overnourished or

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undernourished are they underused or adequately muscled and are they metabolically healthy or not exercise isn't as bad as nutrition but there's still some tribalism with regards to strength training versus cardio and so on in reality you have to focus on all four of the exercise domains V2 Max is

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the single most powerful marker for longevity those with the bottom quartile of V2 Max are four times more likely to die than someone in the top cortile even the lowest cortile compared to the second lowest quartile has a 50% reduction in all cause mortality so why

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is exercise so beneficial it strengthens the heart maintains the circulatory system improves mitochondrial health and that helps you metabolize both glucose and fat stronger and more muscle helps to support and protect your body and maintain metabolic Health since remember glucose is taken up by the muscles and

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fights against insulin resistance it prompts the body to produce its own endogenous drug-like chemicals which help strengthen our immune system grow new muscle and strengthens our bones going back to the Dex of scale scan and measuring our appendicular lean mass index meaning the muscle mass of your extremities controlled for height you

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see that muscularity is important as we age in a study where the average subject age was 74 at enrollment 50% of those with the lowest almi quartile were dead compared to only 20% in the highest quartile if you're old and not very muscular fear not it's never too late to

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start aa's mom started lifting weights at 67 and it changed her life most of us tend to have an affinity for one type of exercise if you do exercise regularly it's probably lifting weights or running or cycling but likely not a combination of everything but we need a balanced approach to exercise when it comes to

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aging he recounts a story of a friend's mother who passes and sees that the last decade of her life she wasn't really living she couldn't do what she loved her body was holding her back from doing the things she wanted to do for a decade prior to her passing it was from this that he realized he needs to adopt the

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philosophy of a decathlete and apply it to Aging in Olympics decathletes are the most revered they aren't the best at any of the 10 individual events in which they compete but they are the greatest because they are remarkably good at so many different events they are True generalists Q the centenarian decathlon

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think of it as the 10 most important physical tasks you want to be able to do for the rest of your life he starts with a long list of physical tasks like hike 1.5 mil on a hilly Trail get up off the floor under your own power using a maximum of one arm for support pick up a young child off the floor carry two 5 lb

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grocery bags for five blocks lift a 20 lb suitcase into the the overhead compartment of a plane balance on one leg for 30 seconds eyes open and bonus points eyes closed for 15 seconds have sex climb four flights of stairs in 3 minutes open a jar do 30 consecutive jump rope skips these are just examples

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and yours can be something totally different your body will decline as you agage so in order to do any of those things then you need to be able to do much more now to armor yourself against the natural and precipitous decline in strength and aerobic capacity that you will undergo as you age a big part of

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this centenarian de cathlon is to help us redefine what is possible in our later years and wipe away the default assumption that most people will be weak and incapable at that point in their lives the first of the four domains of exercise is aerobic efficiency which we call Zone 2 when you're doing cardio you

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can be in one of five zones or up to seven depending on your training methodology but don't worry if you have six or seven zones because what we're saying with zone two is the same across all of them Zone one is a walk in the park and zone five or six or seven is a Sprint Zone 2 is more effort than a walk

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in the park think of it as the effort where you can barely speak in full sentences or you could talk to someone but they would definitely know that you're exercising on a technical level it's the maximum effort that you can maintain without accumulating lactate because production and clearance is matched you can be a weirdo like me or a

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TIA and prick your finger to measure your lactate quantitatively or you can do the talk test that I just mentioned the reason Zone 2 is so important is that it helps with your mitochondrial health and as we know the mitochondria is the PowerHouse of the cell glucose can be metabolized in multiple ways but

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fatty acids can only be converted to energy in the mitochondria and more effective and healthier mitochondria mean you have a greater capacity to utilize fat being able to use both fuels glucose and fat is what we call metabolic flexibility and it's a good thing but not only does it help with

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your mitochondrial health and prevent chronic illness but it also helps build a base of endurance for anything else you do in life whether riding your bike or playing with your kids or grandkids depending on your level of Fitness a brisk walk may get you to Zone 2 and for others you may need to walk uphill I do

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most of my zone 2 on the indoor trainer as does a TIA but figure out whatever method is enjoyable and sustainable for you he recommends 3 hours of Zone 2 minimum per week or four 45 minute sessions he's a bit of an overachiever so he does four 60-minute sessions and

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since I'm so incredibly slow and unfit on the bike I do closer to five or even 6 hours of Zone 2 on the bike and I've seen a 50% Improvement in my zone 2 power in the last year and a half by doing so the second domain is Max aerobic output V2 Max is a good proxy

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for our physical capability and while Zone 2 helps to increase it it's only marginal we need to train V2 Max intentionally as well he pushes his patients to train for as high of V2 Max as possible so they can maintain a high level of physical function as they age he wants them to Target the elite range

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for their age and sex which means the top 2% if they achieve that he says good job now let's reach for the elite level for your sex but two decades younger it's an extreme goal for sure but if you couldn't already tell by now he's hardcore they know me your V2 Max will

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decline by roughly 10% per decade and up to 15% per decade after the age of 50 he recommends supplementing your Zone 2 workouts with one or two V2 max workouts per week essentially 80% of your cardio should be Zone 2 and 20% should be V2 work V2 Max intervals are about 3 to 8

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minutes in length which is longer than hit which are usually 30 seconds to a minute he recommends a 4x4 protocol where you go as hard as you can for 4 minutes and then 4 minutes of an easy pace for your heart rate to come back down below 100 beats per minute and then repeat that four times or up to six

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times if you're an overachiever and then cool down for those on the bike he finds that the ideal V2 Max Pace works out to about 33% more than your Zone 2 power or alternatively 120% of FTP for 3 minute intervals and 106% of FTP for 8 Minute

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intervals next is strength muscle mass begins to decline as early as our 30s and we lose muscle strength about 2 to three times more quickly than we lose muscle mass this is because as we age there's atrophy in the type two muscle fibers which are the fast twitched fibers think of strength training as a

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form of retirement savings just as we want to retire with enough money saved up to sustain us for the rest of our lives we want to reach older age with enough of a reserve of muscle and bone density to protect us from injury and allow us to continue to pursue the

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activities that we enjoy it's better to save and invest and plan ahead letting your wealth build gradually over decades then to scramble to try to scrape together an individual retirement account in your late 50s and hope the stock market works out strength training also helps with bone mineral density or

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bmd which is also assessed by the dexa scan we discussed earlier bmd diminishes on a parallel trajectory to muscle mass peing as early as our late 20s before beginning a slow steady decline onethird of people over 65 who fractured their hip are dead within a year which is why

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I was freaking out back in medical school when my grandmother in her mid to late ' 80s broke her hip but she's a fighter and lived for several years after that a big part of that is we can lose muscle and ability incredibly fast with inactivity it's the beginning of a steep decline from which we may never

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recover luckily for my grandmother my mom got on her case possibly in part from me pestering her with the importance of activity and rehab immediately after hip replacement surgery to improve outcomes one of the most important measurements of strength is how much heavy stuff you can carry I know even more important than the size

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of your bike BPS or how much you can bench shocking carrying things is one of our superpowers as a species which is why farmer carries are such a great exercise he wants male patients to carry one half of their body weight in each hand so full body weight in total for at least 1 minute and for female patients

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75% of body weight alternatively dead hang from a pull-up bar for 2 minutes for men and women for 90 seconds at the age of 40 as you age they scale that Target down a bit this is also relevant to grabbing something to keep yourself from falling and getting a hip fracture as you age here's how a structures his

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strength training first grip strength second concentric and Ecentric loading for all movements concentric is the muscle shortening phase like squeezing up on a bicep curl and the Ecentric is the elongation phase returning it to that starting position third pulling motions at all angles from overhead to

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in front of you and finally hip hinging movements such as the deadlift and squat but also step UPS hip thrusts and single leg variants to strengthen the legs glutes and lower back these are the four he finds most relevant to the centenarian de Cath on finally we're on to stability which he defines as the

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subconscious ability to harness decelerate and stop Force the main reason this is so important is for injury prevention older people tend to exercise Less in large part because they can't from hurting themselves in some way and so they continue to decline my take is first absolutely avoid injury

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but if you do get injured find ways to work around it like when my right chronic shoulder injury was exacerbated late last year I took several intentional steps to keep doing lower body strength training plus upper body rehab work until I could start doing proper upper body strength training again to avoid injury we first need to

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break out of the mentality that we need to crush all of our workouts every single time to constantly hit PRS instead focus on doing things right and cultivate safe ideal movement patterns that allow our bodies to work as designed and reduce our risk of injury most acute injuries like a torn ACL are

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rarely sudden the onset may be rapid but there was likely a chronic weakness or lack of stability at the foundation of the joint joint that was the true culprit stability allows us to create force in the safest way possible connecting our body's different muscle groups with much less risk to our joints

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soft tissue and spine going back to Ecentric strength it's often a failure of stability and Ecentric strength that results in Falls and injuries later in life so control the negatives and don't just drop the weights back to its starting position he is very Pro DNS or dynamic neuromuscular stabilization the

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idea is that the sequence of movements that young children undergo on their way to learning how to walk is not random or accidental but part of a program of neuromuscular development that is essential to our ability to move correctly moving correctly is so important to avoiding injury that he

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doesn't even push strength training to his patients until they have established some level of stability it's just not worth the risk he goes into greater depth with the importance of breathing for movement patterns toe yoga to help with foot function since after all most movements begin with us having our feet planted on the ground and multiple other

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helpful exercises you can find the videos on his website linked below along with links to his DNS and postural restoration Institute recommended resources you should also consider filming yourself working out from time to time just to compare what you think you're doing to what you're actually doing he does this daily with his phone

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and tripod filming the 10 most important sets each day and watching the video between sets comparing what he sees to what he thinks he's doing I actually do the same thing with a virtual coach who can help guide me and point out things that I'm missing even when I'm reviewing the video I've worked with traditional pts many many times over the years years

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including last December and January because of my rotator cuff injury but I never got lasting relief so I purchased Trevor hash's bulletproof shoulders I did his program along with the one-on-one coaching and I filmed many of my sets I sent them to him and we created a custom routine based on my unique deficits and movement patterns

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and I'm happy to say that I'm finally back to doing upper body strength training I have no affiliation or incentive to even say this but for those who have found themselves frustrated with chronic injuries and movement deficits he saved my sanity and my ability to do upper body strength training his info is down in the description and you may find similar

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results with him or others who don't subscribe to a single methodology but rather incorporate multiple modalities into their approach last but not least we're on to nutrition or nutritional biochemistry as he likes to call it there's extreme tribalism to nutrition and it's really just the dun and Krueger

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effect in action those with the highest degrees of certainty yelling loudly about how their diet is correct are largely the most ignorant ones I was one of these people in some form I was plant-based for almost 5 years and while I'm grateful that I never tried to shove it down anyone's throat and convert

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people I did strongly believe that it was scientifically the optimal way to eat funny enough AA says he was also on Mount stupid in the past as well having done ketogenic and vegan diets too and believing at the time that they were the one and only optimal way of eating and this points to the underlying assumption

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in the diet Wars and nutrition research that there's one perfect diet that works best for everyone with nutrition 3.0 we're looking for scientifically rigorous highly personalized decision- making driven by feedback and data rather than ideology or labels

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unfortunately while exercise can almost magically improve health span and lifespan nutrition doesn't have the same Powers the fundamentals to nutrition are relatively simple don't eat too many calories or too few consume sufficient protein and essential fats obtain the vitamins and minerals you need avoid

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pathogens like eoli and toxins like Mercury or lead and beyond that we know relatively little with complete certainty directionally the cliche expressions are likely correct if your great-grandmother would not recognize it you're probably better off not eating it if you bought it on the perimeter of the

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grocery store it's probably better than if you bought it in the middle of the store plants are very good to eat animal protein is safe to eat we evolved as omnivores and therefore most of us can probably find Excellent Health as omnivores the reason we don't know much about nutritional biochemistry is

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because nutrition research is quite poor leading to bad reporting that media lots of arguing on social media and rampant confusion among the public the main issues with nutrition research are the following first it's primarily epidemiologic studies which are notoriously bad at distinguishing

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between correlation and causation second the effect sizes are so small they could be due to other confounding factors third many of the data collection methods are complete jokes like food frequency questionnaires asking people to remember how often or what they've eaten in the past just try remembering

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what you ate 2 weeks ago for for lunch to see why this is completely useless and fourth healthy user bias which is one of the largest issues those that are health-minded tend to have clusters of behavior and the thing you're testing let's say a vegan diet is likely subject to this so what actionable steps can we

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take on diet there are three levers we can use when making dietary changes first caloric restriction or CR eating less than total but without attention to what is being eaten or when it's being eaten second is dietary restriction or Dr eating less of some particular

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elements with within the diet like meat or sugar or fats and finally time restriction or TR whereby we restrict eating to certain times up to and including multi-day fasting CR is of course the easiest to understand and in animal models it appears that eating fewer calories extends your life this

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was hot new stuff back when I was in college around 2010 but even back then it was controversial let's summarize it with the following there were two studies looking at monkeys the Wisconsin study and the NIH study monkeys that ate fewer calories in the Wisconsin study lived longer but there was no difference in lifespan for NIH monkeys the main

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difference in the studies was the type of food they ate Wisconsin monkeys ate garbage junk food whereas NIH monkeys ate higher quality food long story short since the NIH diet was much higher quality giving more or less had a smaller impact because the diet wasn't

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as harmful to begin with if you're eating junk food it's better to eat much less of it but if your diet is high in quality to begin with and you're metabolically healthy then not eating to excess is beneficial but beyond that does not much benefit you'll find that by eating a healthier diet you'll

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naturally consume fewer calories too because of the macronutrient and fiber makeup of your diet now most diets focus on Dr limiting what you actually eat and it's also where people focus all of their anger and arguing online there are certain things we should all eliminate

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like sugary beverages but beyond that the biggest issue is everyone's metabolism is different I tried a keto diet for a week and it absolutely destroyed my GI system does that mean that no one should do keto and keto is never a good idea obviously not some

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people will lose lots of weight and improve their metabolic markers on a low carb or keto diet While others will actually gain weight and see their lipid markers go Haywire on the exact same diet conversely some people might lose weight on a lowfat diet While others will gain weight alcohol has no

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physiologic benefits and studies suggesting it's healthy are plagued by issues such as the healthy user bias however a tea drinks relatively frequently because of social or emotional benefits he recommends fewer than seven servings of alcohol per week with ideally no more than two on a given

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day I still think that's a bit on the higher end now let's go through each of the macronutrients starting with carbs AA is a huge proponent of cgms for his patients even those who are not diabetic they're more accurate and actionable than a hemoglobin A1c but those against the idea say that first it's too

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expensive and two there's no RCT data showing the benefit in non-diabetic patients regarding cost Atia points out most people only need it for a few months to get the value and plus with time and more non-diabetics using it it'll drive cost down and for the RCT side that's a valid critique but things

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are moving so fast and there might be data soon showing benefits but existing data looking at blood sugar in non-diabetics is already noteworthy there was a 2011 study looking at 20,000 people mostly without type 2 diabetes which found that their risk of mortality increased monotonically with their

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average blood glucose levels measured bya hemoglobin A1c the higher their blood glucose the greater their risk of death even in the non-diabetic range of blood glucose another study in 2019 looked at the degree of variation in subject's blood glucose levels and found that people in the highest quartile of

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glucose variability had a 2.67 times greater risk of mortality than those in the lowest or most stable cortile again this brings up the evidence informed versus evidence-based discussion from earlier when putting patients on a CGM he notices two distinct phases first the

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Insight phase where they learn how different foods exercise sleep and stress affects blood sugar in real time this primarily happens in the first month and second the behavior phase where the Hawthorn effect is activated whereby people modify their behavior when they're being watched the goal here

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is to keep your average blood glucose at or below 100 mes per deiler with a standard deviation of less than 15 higher standard deviation means there are greater fluctuations and probably much more insulin is being required to bring their glucose under control this is a key early warning sign of

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hyperinsulinemia you'll find a ton of other insights with a CGM such as people tend to be more insulin sensitive in the morning than in the evenings so it makes sense to frontload your carb consumption earlier in the day you'll also find that your carb tolerance is heavily influenced by other factors such as your

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activity level and sleep again tying these things together you'll find that zone 2 ant endurance work helps with glucose disposal as does greater muscle mass allowing you to not spike your blood sugar as easily and that brings us to levels who sponsoring this part of the video I've been using their product

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almost daily now since 2019 because you're not only only getting the functions and benefits of a CGM as AA outlines in outlive but combining it with a more powerful app to gain further actionable insights levels since the beginning has already provided more value and utility than a regular CGM by

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allowing you to log your meals with photos and descriptions as well as exercise to gain greater insight into how Foods affect you as each person responds differently to the same foods but now they've added a new feature called habit Loops which allows you to set daily targets and track progress for Nutrition Fitness and Wellness habits

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part of this is macr tracking which lets you track your protein and fiber intake which are very important to metabolic Health as we'll discuss shortly but you can also track sleep steps workout time and so on in short their app gives you the benefits of cgms that AA discusses but it adds additional benefits too

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things like protein and fiber tracking exercise goals and sleep which AA also emphasizes heavily they're also currently running a large scale observational research study to better understand CGM data and non-diabetic individuals some of the most exciting preliminary data is around weight loss specifically that levels users that

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begin with a high BMI greatly decrease it and there's a strong correlation between food logging and decreasing your BMI it's a strong Testament to you can't manage what you don't measure use the link on the description for two free months on your annual membership and check out why I even got my mom on their product for the metabolic health

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benefits in this video right up here now here are aa's lessons from wearing a CGM you can find my list which is a bit different in the video Linked In the description less processed carbs and those with more fiber help to blunt glucose impact he tries to eat at least 50 gr of fiber per day rice and oatmeal

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are surprisingly glycemic meaning they cause a sharp rise in glucose despite not being particularly refined more surprising is that brown rice is only slightly less glycemic than long grain white rice fructose does not get measured by a CGM but because fructose is almost always consumed in combination

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with glucose fructose heavy foods will still likely cause blood sugar spikes timing duration and intensity of exercise matters a lot generally aerobic exercise is more efficacious at removing glucose from circulation whereas high intensity exercise and strength training

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tend to increase glucose transiently because the liver is sending more glucose into the circulation to fuel muscles so don't be alarmed if your glucose spikes while exercising good versus bad sleep makes a world of a difference stress bio cortisol and other stress hormones has a surprising impact

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on blood sugar even when fasting or restricting carbs I've actually noticed something similar with solumedrol a corticosteroid that I was given prior to my medication infusions for inflammatory bowel disease and I would see my blood sugar elevated for the rest of the day even if I completely avoided carbs I've

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since stopped getting this steroid premedication non-starchy veggies such as spinach or broccoli have virtually no impact on blood sugar so eat as much as you want foods high in both protein and fat eggs beef short ribs Etc have virtually no effect on blood sugar but large amounts of lean protein like

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chicken breast will Elevate glucose slightly protein shakes especially if low in fat have a more pronounced effect particularly if they contain sugar stacking multiple factors either good good or bad is very powerful for example if you're stressed out sleeping poorly and unable to make time to exercise then

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be careful with what you eat the most important Insight is that simply tracking his blood sugar has a positive impact on his eating Behavior as the CGM creates its own Hawthorn effect now on to protein in short most of us are underc consuming protein if you're concerned about overc consumption rest

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assured that excess protein you can't synthesize into lean mass will be excreted in the urine as Ura or used for gluconeogenesis the generation of glucose from other substrates the recommended daily allowance or RDA for protein is8 G per kilog per day but

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elderly people consuming the RDA will lose muscle mass in a period as short as 2 weeks how much protein is needed is variable he recommends 1.6 G per cake per day minimum for his patients which is twice the RDA and for active people with normal kidney function 1 G per

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pound of body weight or 2.2 G per cake per day is a good place to start so for someone 180 lbs like me they need to consume 130 gram of protein per day minimum and up to 180 gram it's actually quite difficult the best way to approach this and to make sure your body can

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actually use each bolus of protein is to split it into four or more servings throughout the day each with about 025 G per pound of body weight the reason is that if you consume more than 40 to 50 g in a single seating your body can't actually use that for muscle synthesis and it can't store the excess for later

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most people do not need to worry about consuming too much protein it requires incredible effort to eat more than 3.7 kigs per gram per day or 1.7 G per pound which is the safe upper limit of protein consumption resulting in too much stress on the kidneys keep in mind as you age

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anabolic resistance sets in meaning it's harder to gain muscle therefore older people may require more protein AA generally consumes a protein shake a high protein snack and two protein meals a good way to track this is with levels macr tracking all you have to do is take

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a photo or describe your meal and it will estimate your macronutrients of the meal including how many G a protein to help you hit your targets each day both plant or animal-based proteins are fine but keep in mind if you're doing plant protein it is far less bioavailable than animal sources only about 60 to 70%

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bioavailability plant protein also has less of the essential amino acids methionine lysine and tryptophan potentially leading to reduced protein synthesis this also applies to whey versus soy protein isolate let's talk fat there are three main types saturated fatty acids monounsaturated fatty acids

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and poly saturated fatty acids which are broken down further into Omega 6 and omega3 Omega-3s are further broken down into Marine which is EPA and DHA and non-marine sources which is ala it's best to boost your mufa closer to 50 to 55% your SFA down to 15 to 20% and

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adjust the total pufa to fill the Gap you can supplement EPA and DHA with fish oil and the amount can be tight Trad by doing a blood test to measure your levels of all fatty acids and the Omega 6 to Omega-3 ratio typically this means eating more olive oil avocados nuts cutting back on but not eliminating

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butter and lard and reducing omega-6 Rich corn soybean and sunflow oils while also looking for ways to increase omega-3 pufas from sources like salmon and anchovies going back to the three levers in nutrition we have TR or Tim restricted feeding there's short-term

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eating Windows alternate day fasting and multi-day fasting short-term intermittent fasting was the hot new trend with 168 protocols being the most popular but you can also use more narrow Windows like 186 or 24 meaning you fast for the first number let's say 16 hours in a day and eat for the second number 8

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hours in this example the issue is that this is a big extrapolation from research in mice but a mouse only lives for 2 to 3 years and will die after 48 Hours of no food so a 16-hour fast for them is essentially a multi-day fast for a human plus 16 hours of fasting isn't

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enough for us to activate autophagy or act on other beneficial Pathways like mtor inhibition you are unfortunately much more likely to miss your protein window by going too aggressive here particularly if you go to the extreme of omod or 1 meal a day and limit eating to

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just one or two hours per day alternate day fasting can help you lose weight but again Pro the literature you're probably going to lose more muscle mass compared to patients who just eat 25% fewer calories every day multi-day fasting has the largest effect on both muscle mass and reducing physical activity levels

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and these two costs for most patients don't outweigh the benefits using something like multi-day fasting should be so carefully and deliberately keeping these costs in mind to sum up nutrition bad nutrition can hurt us more than good nutrition can help us if you're already metabolically healthy nutritional

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interventions can only do so much most people are going to be overnourished but also underused Zone 2 training can have a huge impact on our ability to dispose of glucose safely and our ability to access the energy we have stored as fat saturated fat can raise apob in some

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people but it's easy to control pharmacologically excessive carb intake can have spill effects in the form of elevated triglycerides if there's one food he would eliminate from everyone's diet it would be fructose sweetened drinks including both sodas and fruit juices but I love his concluding

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paragraph if after reading this chapter you're upset because you don't quite agree with some detail I've covered be it the ratio of mufa to pufa to SFA or the exact bioavailability of soy protein the role of seed oils and lectin or the ideal Target for average blood glucose

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levels or if I have offended your sensibilities because I didn't say your diet is the best diet I have one final piece of advice stop overthinking nutrition so much put the book down go outside and exercise finally we're on to sleep he starts the chapter with a story

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of him falling asleep behind the wheel to which I say come on Peter don't be riding the clutch at a red light you're going to cause the Thro bearing to fail prematurely but he makes a good point sleep deprivation in medicine is not only tolerated but cultivated as I've discussed many times on this channel and

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on med school insiders it's it's ironic since those in medicine are supposedly promoting Health yet are taking a huge hit to their own since this video is already insanely long I'll summarize the Sleep chapter with the following sleep deprivation increases your risk of injury if you're chronically sleep deprived you probably underestimate the

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effects since you've adapted to it people who are sleep deprived have older looking flabbier skin even in the short term sleep deprivation can cause profound insulin resistance try it for yourself with the CGM high stress can make us sleep poorly which makes us feel more stressed which is a disastrous feedback loop

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High overnight glucose on your CGM is almost always a sign of excessive cortisol and sometimes exacerbated by late night eating and drinking here's how to improve your sleep no alcohol and if you must limit yourself to one drink prior to 6 p.m. don't eat within 3 hours of bedtime you want to go to bed just

53:42

slightly hungry abstain from stimulating electronics for 2 hours before bed reduce blue light exposure with night shift or similar to transfer to warmer colors for at least 1 hour before bed avoid anything that is activating or stimulating like work or social media sauna or hot tub before bed can help you

53:59

cool and Signal sleep to your brain the room should be cool and getting a cooling mattress or device like the eight sleep which both Atia and I use linked below for a special discount is a game changer here darken the room completely you shouldn't be able to see your hand in front of your face give yourself enough time to sleep be

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consistent with your sleep and wake times and don't obsess over your sleep if you're the type to get anxious from poor sleep metc on your sleep tracker then consider taking some time away from it these are a great start but I do actually have several more sleep tips as it's something I grew quite let's say

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passionate about during both medical school and residency so check out how to wake up early and not be miserable or another sleep video in the playlist link below those who follow this channel know how much I love Peter AA and his work a big part of that is that we have a surprising amount in common but there are also some things I think he can do

54:47

better first many of the critiques you'll see online center around his obsession with stability and how there's a lack of evidence around his suggestions I'd Point those people to the evidence based versus evidence ined discussion but I do think his singular focus on DNS over other movement or

55:02

stability schools of thought is unusual while it's his chosen philosophy and I don't have anything against it there's value to working with those who borrow from multiple schools of thought which is one of the reasons I've enjoyed working with Trevor more than physical therapists befor him but overall aa's focus on proper movement and improving

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stability is sound even if DNS isn't the only method to do so second you'll see people rail against his Nutrition chapter as expected and especially especially vegans or those on a plant-based diet talk about how there is irrefutable evidence of that diet being Superior I think aa's Nutrition chapter

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concluding paragraph is a perfect response to this and he's already done enough to talk about the shortcomings of nutritional research namely healthy user bias and epidemiologic study shortcomings which we don't need to go into further but the thing I find the most strange is that he's adamant about giving off the impression that he was a

55:50

surgical oncologist which he never was he spoke on Zog MD's podcast about doing 3 years of general surgery residency prior to dropping out but if you look at his prior Ted Talk descriptions or his author bio on the book or how he even discusses his time in medicine in the book he disingenuously gives the

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impression that he was a surgical oncologist which requires him to finish general surgery residency and a Surgical Oncology Fellowship I've pointed this out before and had commenters even argued the point that he was a surgical oncologist that's the level of deception occurring here his NIH Surgical Oncology

56:24

Fellowship was a research Fellowship which often occurs in the middle of a general surgery residency not an actual Surgical Oncology Fellowship that you're led to believe the one that you complete after finishing 5 to 7 years of general surgery residency and the one that makes you a surgical oncologist no shade I

56:40

quit plastic surgery residency but one should be open and honest about that AA has told stories on his podcast about being uncomfortable with people calling him doctor and I think part of that is probably the shame or guilt that arises from not being fully transparent with his credentials even without completing

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a surgical residency or Fellowship I still think he's an expert on what he's discussing as credentials aren't everything and even if someone does prioritize credentials Above All Else surgical residency and Surgical Oncology Fellowship has little relevance to the type of longevity practice he does now I

57:11

also think it would be more powerful if he spoke a bit more about his back injury due to deadlifting he spoke about it openly on his blog but in the book mentions it as a mystery back injury I mean I got a deadlifting back injury too at 20 years old and my SI joined thank no surgery and it makes for a great

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point to highlight the importance of proper movement patterns and stability in conclusion there is a ton here and it might be overwhelming knowing where to start AA recommends starting with the thing that you're most likely to succeed in if your sleep sucks then start there and don't focus on exercise or nutrition

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yet that'll make the next steps of tackling the others easier and also build your confidence moving forward to reemphasize an important Point exercise is the miracle drug which you have to earn no matter who you are there's no magic pill there put in the effort and make it count I find doing meetings on

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the bike while doing Zone 2 a powerful hack to multiply time and get more zone two than I otherwise would have time for especially if I'm also strength training on those days find a doctor who is willing to work with you in a medicine 3.0 capacity my mom loves working with doctors that have her same background

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who were trained in a country that has a different culture of medicine where the doctor knows everything and can't be wrong despite me hopping on the virtual phone visit with my mom and the doctor and asking the doctor to order some simple Labs like apop and LPA this doctor thought that they knew more than

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they did and they didn't want to prioritize my mom's health despite them frequently returning to the literature vaguely without being able to cite any concrete numbers on ranges or publication dates or even authors they agreed to order the tests and then never did that's some clown behavior I'm now

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helping my mom find a better physician who is willing to be a lifelong learner as every doctor should be and help their patients be on top of their health and The Cutting Edge research rather than feeding some ego of already knowing everything the final chapter of aa's book covers his own deeply moving story with emotional health and therapy and

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the incredible low he experienced I can't do it justice by summarizing it and I suggest you buy a copy of his book yourself to give it a read I've put in more time into this video than any other video I've done to date and it would mean a lot to me if you use our affiliate link below to purchase his book as a small way to support our

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channel that costs you nothing much love and wishing you the best of health