#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
In this AMA episode, Peter Attia, MD and co-host Nick Stenson answer listener questions on diverse health topics including cardiovascular assessment, fasting methods, alcohol's impact, nutrition principles, and exercise routines for optimal well-being.
Deep Dive Analysis
5 Topic Outline
Assessing Cardiovascular Health and Risk Factors
Fasting and Time-Restricted Eating for Metabolic Health
Alcohol Consumption: Health Risks and Epidemiological Challenges
Reconciling Alcohol's Risks with Social Enjoyment
Key Principles for a Well-Balanced, Healthy Diet
8 Key Concepts
Heritable ASCVD Causes
Genetic predispositions that lead to early onset or severe atherosclerotic cardiovascular disease, often indicated by family members requiring procedures like stents or bypass surgery at a young age. The two most common forms are LP(a) and familial hypercholesterolemia.
Calcium Scan (CAC)
A test that measures calcification in the arteries, indicating advanced cardiovascular disease. While a zero score is ideal, there's a 15% false negative rate, meaning soft plaque might still be present.
APOB
An aggregate marker for all atherogenic proteins, which are particles that can contribute to plaque formation in arteries. It's considered a more important lipid marker than LDL cholesterol.
LP(a) (Lipoprotein(a))
A specific type of lipoprotein that is highly atherogenic, meaning it significantly contributes to the development of atherosclerosis. It needs to be tested separately from APOB because even elevated LP(a) might not significantly raise APOB levels.
Time-Restricted Feeding (TRF)
A feeding pattern where all daily calories are consumed within a specific, narrow window of time, such as 8 or 6 hours, with the remaining hours being a non-eating period. This is what many people refer to as 'intermittent fasting'.
Prolonged Fasting
A period of not eating that extends beyond a single day, typically lasting 2-3 days, or even up to 7-14 days, during which only water and non-caloric liquids are consumed.
Dietary Restriction
A strategy to reduce total calorie intake by imposing significant limitations on what foods are eaten, rather than focusing on when or how much is eaten. The more restrictive the diet, the more likely it is to reduce calories.
Mendelian Randomization
A research technique that uses genetic variants (genes) that are associated with a specific trait (like alcohol consumption) to infer causal relationships between that trait and health outcomes, helping to overcome some limitations of observational epidemiology.
7 Questions Answered
Start by understanding family history of heart disease, especially early onset. Then, consider a calcium scan (CAC), lipid profile focusing on APOB and LP(a), and consistently monitor blood pressure correctly.
'Intermittent fasting' or 'time-restricted eating' typically refers to daily patterns of not eating for a certain number of hours (e.g., 16-8), while 'fasting' is reserved for prolonged periods of water-only, non-caloric intake lasting more than a day.
Data suggests that time-restricted feeding is no better than straight caloric restriction; the primary benefit for metabolic health comes from the reduction in total calories consumed, regardless of the eating window.
Calories can be reduced directly by counting and restricting them, indirectly by narrowing the feeding window through time-restricted eating, or by imposing significant restrictions on what foods are eaten (dietary restriction).
Alcohol is a dense source of energy and its metabolism produces toxic byproducts. While epidemiology shows small hazard ratios, Mendelian randomization suggests any increase in alcohol consumption leads to an increase in mortality and risk of diseases like cardiovascular disease, dementia, and cancer.
Yes, women generally fare worse with respect to alcohol than men, partly due to lower body weight and lean mass, and also because they tend to have less alcohol dehydrogenase, an enzyme crucial for alcohol metabolism.
While social interaction is beneficial, it's important to consider the dose of alcohol; low, infrequent consumption is likely not terribly bad, but escalating doses are quite negative and should be evaluated against potential negative impacts like impaired sleep or poor food choices.
16 Actionable Insights
1. Stop Smoking
Eliminate smoking entirely, as it causes an enormous increase in your risk of cardiovascular disease.
2. Address Metabolic Unhealthiness
Actively manage and improve your metabolic health, including conditions like hyperinsulinemia, insulin resistance, and type 2 diabetes, to significantly reduce your risk of cardiovascular disease.
3. Prioritize Calorie Restriction
To improve metabolic health, focus on restricting total caloric intake, as this is the primary factor that provides the greatest benefit, regardless of the method used.
4. Consider Alcohol Abstinence
Seriously consider abstaining from alcohol entirely, as it is not an essential nutrient, provides no inherent health benefits, and is associated with increased mortality and disease risk.
5. Understand Family History
Thoroughly investigate your family history for cardiovascular disease, asking specific questions about how relatives lived and died, including medication use for cholesterol or blood pressure, to identify potential heritable risks like LP little a or familial hypercholesterolemia.
6. Measure Blood Pressure Correctly
Accurately assess your blood pressure by resting for five minutes before checking, using a correctly fitting cuff at mid-chest level, not crossing your legs, and taking duplicate or triplicate readings twice a day for a couple of weeks, once a year. Aim for readings below 120/80 mmHg.
7. Focus on APOB and LP(a)
Assess your cardiovascular risk by prioritizing your lipid profile, specifically APOB and LP little a levels, as these are the most critical markers for atherogenic proteins, making other cholesterol metrics less important.
8. Manage Triglycerides (If High)
Monitor triglyceride levels, but only manage them if they are dramatically elevated (north of 400 mg/dL), as levels below this threshold are less concerning once APOB and LP(a) are known.
9. Consider a Calcium Scan (CAC)
Evaluate for existing arterial damage by considering a calcium scan (CAC), which can indicate advanced disease and the presence of plaque, though a zero score has a 15% false negative rate.
10. Experiment with Calorie Methods
Try different calorie reduction techniques—direct counting, time-restricted feeding, or dietary restriction—to discover which method best suits your lifestyle and preferences, understanding each has distinct pros and cons.
11. Be Judicious with Alcohol
If you choose to consume alcohol, do so judiciously and critically evaluate if it negatively impacts other aspects of your life, such as sleep quality or eating habits.
12. Limit Daily Alcohol Intake
If consuming alcohol, limit intake to conservatively one drink per day to minimize potential health risks, acknowledging that women generally fare worse with alcohol than men.
13. Avoid Alcohol Before Bed
Refrain from drinking alcohol too close to bedtime, as it is known to disrupt sleep quality, which can be observed using sleep trackers.
14. Mind Alcohol’s Caloric Load
Be aware that alcohol is a calorie-dense nutrient (7 kcal/gram) and can contribute significantly to your total caloric intake, especially if you are a moderate to heavy drinker.
15. Moderate Social Drinking
If consuming alcohol for social enjoyment, a pattern of three or four beers a couple of times a month is considered by the speaker to be ‘probably not that bad’.
16. Do Not Use CIMTs
Avoid using Carotid Intima-Media Thickness (CIMT) tests for cardiovascular risk assessment, as they are not considered sufficiently helpful or supported by data.
5 Key Quotes
The calcification of the artery per se isn't necessarily the thing that's going to kill a person. But it's indicative of very advanced disease.
Peter Attia
The good news is that you don't have to concern yourselves with LDL cholesterol, non-HDL cholesterol, HDL cholesterol. None of those things actually matter once you know the APOB and the LP little a.
Peter Attia
It's the calorie restriction that provides the greatest benefit. How you go about achieving it is really a function of your style.
Peter Attia
Alcohol is under no dose helpful. Under low doses, probably not terribly bad. But under escalating doses, it's actually quite negative.
Peter Attia
I don't want to dismiss the importance and the benefit of social interaction and the joy that comes from that.
Peter Attia
1 Protocols
Correct Blood Pressure Measurement
Peter Attia- Sit for five minutes, doing nothing, resting before the blood pressure is checked.
- Ensure the cuff fits correctly.
- Position the arm at the level of the right atrium (about mid-chest).
- Do not cross legs when it's checked.
- Check blood pressure in duplicate or triplicate.
- Perform this measurement twice a day for a couple of weeks, once a year, for a real assessment.