podcast Peter Attia 2023-02-13 topics

#242 - AMA #44: Peter's historical changes in body composition with his evolving dietary, fasting, and training protocols

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Show notes

In this “Ask Me Anything” (AMA) episode, Peter reviews the last 12+ years of his DEXA scan results revealing the changes to his body composition, lean muscle mass, visceral adipose tissue, and more. He explains how his body composition and blood biomarkers were impacted by the various dietary approaches (ketosis, fasting, high protein, etc.) and training protocols (primarily endurance, primarily strength training, etc.) he has undertaken over the years. Furthermore, Peter explains his planned approach moving forward following his most recent DEXA scan in late 2022.

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We discuss:

DEXA scans and other methods for tracking body composition [2:30];
Importance of tracking data over time to see trends [10:15];
DEXA scans in 2011: swimming, lifting, and a carb-restricted diet [12:45];
DEXA scans 2012-2014 during Peter’s time on a strict ketogenic diet [18:30];
Blood biomarkers for evaluating metabolic health [25:15];
DEXA scan in 2020 after several years of regularly engaging in time-restricted feeding and prolonged fasting protocols [28:45];
DEXA scan in 2021: shifting focus to adding muscle, high-protein diet, and more strength training [40:00];
DEXA scan in early 2022: eating additional calories and adding blood flow restriction (BFR) to his workouts [44:45];
DEXA scan in late 2022: a dramatic change following shoulder surgery, and the impact of stress [48:30];
Peter’s approach moving forward following his most recent DEXA scan [59:15];
A rundown of the various nutritional methods of energy restriction [1:06:15];
Current thoughts on fasting and key takeaways [1:09:45]; and
More.

The Peter Attia Drive

Peter’s historical changes in body composition with his evolving dietary, fasting, and training protocols

Show Notes

DEXA scans and other methods for tracking body composition [2:30]

In this conversation, Peter will review the last 12+ years of his personal DEXA results

See AMA #40 for more on DEXA scans and how Peter goes through results with patients
During the last 12 years, Peter’s nutritional and training approach has varied pretty drastically
For instance, growing up, his main thing was boxing – a very, very weight driven sport – Every ounce of non-essential tissue you carry into the ring is problematic

Calipers

Back in his younger, boxing days, he relied on calipers for body composition
It’s not the most objective standard and it’s highly dependent on the skill of the individual doing the test
That said, a person who really knows what they’re doing with caliper’s is awfully good and pretty accurate

Hydrostatic testing

Fast forward to Peter’s thirties, he was monitoring body composition using hydrostatic testing
This is where you’re weighed while dry and then weighed again underwater under the conditions of full exhalation
The ratio of those two weights, and the use of Archimedes’ principle , would basically allow them to deduce how much of your weight was fat
That turned out to be a pretty inaccurate way to go about doing things
For no other issue, highly dependent on basically how much air is left in your lungs at the point of exhalation

DEXA scanning

Late 2011, Peter switched over to DEXA scanning
For all intents and purposes, DEXA is the gold standard
It’s a type of x-ray that scans your body that effectively divides tissue into the following buckets very accurately; bone, fat, “other”
The “other” is mostly muscle, but of course it’s also your organs

What DEXA is looking at:

It’s very good at giving total body fat because it’s very accurate at measuring fat
Total body fat divided by total body weight is your body fat percentage
Peter is adamant that his patients get DEXAs scans at least once a year

When going through the results with them, he explains basically the same four things

First, the least interesting metric is your body fat percentage (which is what most people care about)
Secondly, visceral adipose tissue (VAT), which is one of the compartments of fat that is outside of the subcutaneous stores If we’re going to put excess energy away, we want it to be in subcutaneous pockets of fat. As our capacity to store fat there get stretched, we begin to spill over into other places Peter writes in his book that you can think of this like a bathtub Everybody has sort of a different size bathtub—their genetic capacity to store fat in the safe subcutaneous space The water coming in the bathtub is what you’re eating The water leaving the bathtub through the drain is the energy expenditure You will either be net accumulating or net losing water in that bathtub But if you get to the point where you exceed your bathtub’s capacity to hold water and you start to spill over, really bad things happen. Nobody likes to have even a small amount of water on their floors and God forbid, in their drains and heating ducts And that’s basically happening when you start to see visceral fat, when you start to see intra hepatic fat (NAFLD is the earliest stage of that) When you start to see peri pancreatic fat, perinephric fat, pericardial fat, all of these things are really problematic, highly inflammatory and effectively what Peter would call the fourth pillar of disease. For example, if you’re talking about ASCVD, we talk a lot about apoB, blood pressure, smoking, but we don’t want to forget the inflammatory effect of those fat sources
Third thing we care a lot about is bone mineral density (see AMA #37 ) So we care about a person’s Z scores and T scores The Z-score is your age sex matched BMD for your lumbar spine and your hips The T-score is comparing you to a 30-year-old We use the T-score to make the diagnosis of osteopenia One standard deviation both below the mean or osteoporosis Two and a half standard deviations below the mean it’s osteopenia
The fourth thing we look at are the two metrics of muscle mass: appendicular lean mass index (ALMI) and fat-free mass index (FFMI) These are two different methods, to triangulate on the same sort of thing, which is basically how much muscle mass do you have for your height The ALMI is calculated by looking at the lean mass in your arms and legs in kilograms, dividing that by your height in meter squared The FFMI takes the total fat-free mass in your body and divides that by your height in meter square FFMI is a much bigger number than ALMI The absolute numbers aren’t what matters, what matters is where do you show up on the nomogram for your age and your sex Peter wants his patients to be north of the 75th percentile for ALMI and FFMI
If we’re going to put excess energy away, we want it to be in subcutaneous pockets of fat.
As our capacity to store fat there get stretched, we begin to spill over into other places
Peter writes in his book that you can think of this like a bathtub Everybody has sort of a different size bathtub—their genetic capacity to store fat in the safe subcutaneous space The water coming in the bathtub is what you’re eating The water leaving the bathtub through the drain is the energy expenditure You will either be net accumulating or net losing water in that bathtub But if you get to the point where you exceed your bathtub’s capacity to hold water and you start to spill over, really bad things happen. Nobody likes to have even a small amount of water on their floors and God forbid, in their drains and heating ducts And that’s basically happening when you start to see visceral fat, when you start to see intra hepatic fat (NAFLD is the earliest stage of that) When you start to see peri pancreatic fat, perinephric fat, pericardial fat, all of these things are really problematic, highly inflammatory and effectively what Peter would call the fourth pillar of disease. For example, if you’re talking about ASCVD, we talk a lot about apoB, blood pressure, smoking, but we don’t want to forget the inflammatory effect of those fat sources
Everybody has sort of a different size bathtub—their genetic capacity to store fat in the safe subcutaneous space
The water coming in the bathtub is what you’re eating
The water leaving the bathtub through the drain is the energy expenditure
You will either be net accumulating or net losing water in that bathtub
But if you get to the point where you exceed your bathtub’s capacity to hold water and you start to spill over, really bad things happen.
Nobody likes to have even a small amount of water on their floors and God forbid, in their drains and heating ducts
And that’s basically happening when you start to see visceral fat, when you start to see intra hepatic fat (NAFLD is the earliest stage of that)
When you start to see peri pancreatic fat, perinephric fat, pericardial fat, all of these things are really problematic, highly inflammatory and effectively what Peter would call the fourth pillar of disease.
For example, if you’re talking about ASCVD, we talk a lot about apoB, blood pressure, smoking, but we don’t want to forget the inflammatory effect of those fat sources
So we care about a person’s Z scores and T scores
The Z-score is your age sex matched
BMD for your lumbar spine and your hips
The T-score is comparing you to a 30-year-old We use the T-score to make the diagnosis of osteopenia One standard deviation both below the mean or osteoporosis Two and a half standard deviations below the mean it’s osteopenia
We use the T-score to make the diagnosis of osteopenia
One standard deviation both below the mean or osteoporosis
Two and a half standard deviations below the mean it’s osteopenia
These are two different methods, to triangulate on the same sort of thing, which is basically how much muscle mass do you have for your height
The ALMI is calculated by looking at the lean mass in your arms and legs in kilograms, dividing that by your height in meter squared
The FFMI takes the total fat-free mass in your body and divides that by your height in meter square
FFMI is a much bigger number than ALMI
The absolute numbers aren’t what matters, what matters is where do you show up on the nomogram for your age and your sex
Peter wants his patients to be north of the 75th percentile for ALMI and FFMI

Importance of tracking data over time to see trends [10:15]

Peter has kept a spreadsheet for better part of 12 years where he logs his DEXA data
He keeps track of the various things happening in his life during those phases
There’s a bunch of variables, such as: There’s the passage of time Many changes in nutrition from very strict types of diets to fasting to completely unrestricted eating There’s dramatic changes in the type of exercise he’s been doing Those are really the fundamental three changes
Tracking trends Not only does Peter track his DEXA data, but he does the same with his blood labs He wants to see how does this number compare historically as opposed to looking at this number in isolation It might be a pain to do this, but there’s high value in being able to look at stuff historically to monitor changes Ideally you can take your raw data and present it in graphical form and then include that along with all the historical data in tabular form
There’s the passage of time
Many changes in nutrition from very strict types of diets to fasting to completely unrestricted eating
There’s dramatic changes in the type of exercise he’s been doing
Those are really the fundamental three changes
Not only does Peter track his DEXA data, but he does the same with his blood labs
He wants to see how does this number compare historically as opposed to looking at this number in isolation
It might be a pain to do this, but there’s high value in being able to look at stuff historically to monitor changes
Ideally you can take your raw data and present it in graphical form and then include that along with all the historical data in tabular form

“Trends matter. You’re treating what you see, but you’re mindful of the trends.” —Peter Attia

DEXA scans in 2011: swimming, lifting, and a carb-restricted diet [12:45]

Figure 1. Peter’s historical DEXA scan data.

What you’re looking at is a relatively straightforward spreadsheet that simply records the data going back to May of 2011
The first DEXA scan Peter ever has was the same day that he did a hydrostatic dunk test
On that particular day, Peter completed a hydrostatic dunk test and it said he was 16% body fat which didn’t seem correct
He decided to go and pay the extra cost for a DEXA which showed is body fat to be 9.3% which was more in line with what he felt
W hy was there such a discordance between them ? Unclear, but perhaps he’s someone who can’t get a lot of air out of his lungs and therefore wasn’t giving a good enough underwater weight relative to above water weight
Unclear, but perhaps he’s someone who can’t get a lot of air out of his lungs and therefore wasn’t giving a good enough underwater weight relative to above water weight

DEXA scan results from May 2011

-As you can see, when looking at his DEXA on 5/3/11:

Body weight = just under 179.6 lbs
Lean mass (muscle and organs) = 155.9 lbs
Fat mass = 16.8 lbs
BMC (bone mineral content) = 7.0 lbs
FFM (Fat Free Mass), aka the sum of lean mass and BMC = 162.9 lbs
% body fat = 9.3%
VAT is unknown — unfortunately, this is back when they just didn’t have the software to show VAT They probably gave segmental information on their reports, but he wasn’t paying attention to it at that time
A couple years ago Peter started paying attention to ALMI and FFMI, but they didn’t have the data back then so all it could tell you was fat mass index again, Peter doesn’t really pay much attention to that metric, but he does record it and what my fat free mass index was, and we’ll talk about that Anyway, you can see he doesn’t have his ALMI data until 2014
They probably gave segmental information on their reports, but he wasn’t paying attention to it at that time
again, Peter doesn’t really pay much attention to that metric, but he does record it and what my fat free mass index was, and we’ll talk about that
Anyway, you can see he doesn’t have his ALMI data until 2014

– So, what can we say looking at those May 2011 numbers?

At 38 years old, his 9.3% BF put him in below the third percentile (very lean)
FFMI of 23.4 at that age, it’s above the 97th percentile That’s the highest line in the nomogram
That’s the highest line in the nomogram

-The important question here is: what was he doing at the time?

Exercise: Swimming a ton in the pool Lifting weights like crazy He was doing a bit of cycling as kind of cross-training
Nutrition: He was on a carb-restricted diet but not a ketogenic diet This was actually RIGHT BEFORE he started a ketogenic diet
Swimming a ton in the pool
Lifting weights like crazy
He was doing a bit of cycling as kind of cross-training
He was on a carb-restricted diet but not a ketogenic diet
This was actually RIGHT BEFORE he started a ketogenic diet

DEXA scan results from August 2011

*Note: This was 3 months after going on a ketogenic diet

-Changes in the data:

He lost about 7 lbs (From 180 lbs to 172.5 lbs)
Lean mass went down about 3.5 lbs
Total fat went down by about 4 lbs
BMC doesn’t change
Body fat % went down to 7.5%
FFMI (Fat-free mass index) has also gone down a little bit to 23
Just for reference at that age, Peter’s goal would be to make sure that his FFMI is above about 19 putting him in the 75th percentile (this is the percentile Peter wants his patients in as well)

*A note about discordance between the ALMI and the FFMI:

When there is discordance, Peter prefers the ALMI because we actually have more data for ALMI
ALMI is also a slightly more pure measurement because, in your limbs, you really only have muscle, fat and bone The ALMI truly tells you about what its name suggests, the appendicular lean mass index It is the index of muscle mass in arms and legs
The FFMIis also true to its name But it is somewhat confounded by the organs So while Peter tracks that data—because it includes the musculature of the torso—you’ll sometimes see percentile discordance
When we get to more recent data you’ll see that Peter is slightly discordant between those two—his FFMI tends to represent him at a higher percentile than his ALMI “ probably because I just have scrawny little arms ”
The ALMI truly tells you about what its name suggests, the appendicular lean mass index
It is the index of muscle mass in arms and legs
But it is somewhat confounded by the organs
So while Peter tracks that data—because it includes the musculature of the torso—you’ll sometimes see percentile discordance

DEXA scans 2012-2014 during Peter’s time on a strict ketogenic diet [18:30]

All of the DEXA scans from August 2011 through February 2014 were during Peter’s strict keto diet

-So, what was he doing during this period of time?

Exercise: From 2011 to 2012, he transitioned into cycling During this period, his exercise time is about the same (maybe slightly more), but now it’s on a bike He was still lifting weights, but not quite as much He was cycling 5 days a week 2 days were r eally, really long days 3 days were 90 minutes to 2 hours
Nutrition: Ketogenic diet Not really experiencing any downside of a ketogenic diet, other than the restriction that obviously comes from it
From 2011 to 2012, he transitioned into cycling
During this period, his exercise time is about the same (maybe slightly more), but now it’s on a bike
He was still lifting weights, but not quite as much
He was cycling 5 days a week 2 days were r eally, really long days 3 days were 90 minutes to 2 hours
2 days were r eally, really long days
3 days were 90 minutes to 2 hours
Not really experiencing any downside of a ketogenic diet, other than the restriction that obviously comes from it

Figure 2 .

-DEXA results

Peter’s lowest weight was about 164 pounds, but his lowest weight captured on a DEXA was in October of 2012 and that was 167.5 pounds
By that point, his lean mass was down to about 145 pounds Which is 11 pounds less than the initial test in May of 2011
His BF % was 9.5%
FFMI is still about 22
Which is 11 pounds less than the initial test in May of 2011

Getting off the ketogenic diet

Peter decided in the middle of 2014 to get off a ketogenic diet

While all his metrics of health were really good (e.g., blood markers were great, his performance was great, etc.)
Note about performance on a keto diet: It takes while to adapt It took Peter three months to just even get over the hump of feeling miserable when he exercised It took him 18 months to get to the point where he couldn’t distinguish between being on and off carbohydrates
In the middle of 2014 is when he started to experiment with fasting
It took Peter three months to just even get over the hump of feeling miserable when he exercised
It took him 18 months to get to the point where he couldn’t distinguish between being on and off carbohydrates

What explains Peter’s loss of muscle? A lack of protein intake?

Peter says he was definitely not getting as much protein then as he is now, and that played a factor in the loss of muscle
In the 3+ years Peter was in ketosis, he was tracking his blood level of beta-hydroxybutyrate every single day
The mean level over those three years was like 1.73 millimole was the BHB level
You can loosely say that a BHB level of about 0.5 or greater being the threshold of ketosis so there would be no ambiguity that at 1.73, he was well into the keto zone
The reality with keto is that it’s very difficult to get there if you’re consuming sufficient protein
If you’re hitting one gram of protein per pound of body weight, you are invariably kicking off some of that protein into gluconeogenesis, which is effectively raising glucose and kicking you out of ketosis
In fact, Peter has trouble staying in ketosis in 2011 and it was because his protein intake was too high

More about his keto days :

80% of his calories came from fat back in those days
Peter did not see a rise in your lipid levels or apoB levels—a response that a number of people have with keto Some people who get profound inflammation as well, but he didn’t have any of those things
Peter did an oral glucose tolerance test sometime around 2012 or 2013 “It was comical how well I disposed of glucose” and it was also “very bizarre” Because in theory when your carbohydrate restricted, you can sometimes have this paradoxically weird OGTT where your muscles become so insulin resistant in a physiologic response to the restriction of carbohydrates They’re basically doing that to say, “hey, I want to make sure that every one of those 50 grams or whatever of carbs you eat today is going straight to your brain. I’m not going to let the muscle take any.” Despite that, Peter’s fasting glucose that day was about 90 After taking 75 grams of glucola at 30 minutes, it went from 90 to 110 or something like that His insulin barely went above 10 or something Those would be VERY insulin sensitive numbers
Some people who get profound inflammation as well, but he didn’t have any of those things
“It was comical how well I disposed of glucose” and it was also “very bizarre”
Because in theory when your carbohydrate restricted, you can sometimes have this paradoxically weird OGTT where your muscles become so insulin resistant in a physiologic response to the restriction of carbohydrates
They’re basically doing that to say, “hey, I want to make sure that every one of those 50 grams or whatever of carbs you eat today is going straight to your brain. I’m not going to let the muscle take any.”
Despite that, Peter’s fasting glucose that day was about 90
After taking 75 grams of glucola at 30 minutes, it went from 90 to 110 or something like that
His insulin barely went above 10 or something
Those would be VERY insulin sensitive numbers

A need for humility

This is an example of where we need to have a little bit of humility around this
At the time, Peter says that “I very naively assumed my experience with ketosis is the experience [for everyone]”
He was crushing his workouts, his body comp is good, his labs are good, everything is good
So why wouldn’t everybody do this? “ Now just even thinking that or saying that just seems so dumb ” The reality is that there’s actually people who go on ketogenic diets and their lipids go through the roof or they become actually quite insulin resistant or they just gain weight like crazy “ If you think about the Dunning-Kruger effect, I would argue that this was sort of me at the peak of mount stupid, in terms of relatively little expertise, but a high degree of confidence .”
“ Now just even thinking that or saying that just seems so dumb ”
The reality is that there’s actually people who go on ketogenic diets and their lipids go through the roof or they become actually quite insulin resistant or they just gain weight like crazy
“ If you think about the Dunning-Kruger effect, I would argue that this was sort of me at the peak of mount stupid, in terms of relatively little expertise, but a high degree of confidence .”

Figure 3. Dunning-Kruger Effect

Blood biomarkers for evaluating metabolic health [25:15]

Metabolic health markers

Peter mentioned that body fat percentage is very low in importance
More important is: How is your metabolic health?
Nick asks Peter if he can elaborate on what markers Peter thinks are important in understanding metabolic health
For instance, if someone is going to try a new nutritional strategy, what can they monitor to see if it’s having any other effects potentially that are negative outside of maybe their weight on a scale?

Peter’s response using himself as an example :

Lipids

Pay attention to lipids, both advanced and simple lipids

Triglycerides

TGs are always something he’s paying a lot of attention to
Back when Peter was an “unhealthy guy” circe 2009 (post residency) his triglycerides were always north of 150 milligrams per deciliter
During his subsequent keto days, his TGs ranged from as low as 11 or 12 milligrams per deciliter for a fasting triglyceride to maybe as high as 35 or 40

Fasting glucose, fasting insulin, insulin response, homocysteine, C-reactive protein

Also during keto days, his fasting glucose, fasting insulin, insulin response, homocysteine, C-reactive protein were all in good shape
He didn’t pay too much attention to hormones at that time, but he doesn’t recall any issues

Testosterone

Post residency (before keto days), he has really, really low testosterone (5th percentile)
After he began his health journey, his free testosterone bounced back in a big way, solidly into the 30th to 40th percentile

Uric acid

one number that was persistently elevated back in the keto days, was his uric acid which was “through the roof” He didn’t really understand why at the time, but today he would argue that that’s probably because beta hydroxybutyrate is competing for the same transporter in the kidney that uric acid is And anything that raises ketones is going to probably raise uric acid He would only figure this out many years later when he started doing those really, really prolonged fasts (7-10 water-only fasts) During prolonged fasting, his ketones levels were getting very high and he was also seeing uric acid levels get really high While some of that may be due to DNA and RNA turnover, he thinks more of it just has to do with this substrate mix up problem—basically trying to make room for keto excretion in the place of that and having to hang on to more uric acid
High uric acid typically suggests less metabolic health, but again, Peter thinks there’s an explanation for it that is distinct from the normal reasons why elevated uric acid is a marker for bad metabolic health
He didn’t really understand why at the time, but today he would argue that that’s probably because beta hydroxybutyrate is competing for the same transporter in the kidney that uric acid is
And anything that raises ketones is going to probably raise uric acid
He would only figure this out many years later when he started doing those really, really prolonged fasts (7-10 water-only fasts)
During prolonged fasting, his ketones levels were getting very high and he was also seeing uric acid levels get really high
While some of that may be due to DNA and RNA turnover, he thinks more of it just has to do with this substrate mix up problem—basically trying to make room for keto excretion in the place of that and having to hang on to more uric acid

Liver enzymes

In terms of his liver enzymes during ketosis, they were at good levels (always in the twenties)

DEXA scan in 2020 after several years of regularly engaging in time-restricted feeding and prolonged fasting protocols [28:45]

A long gap in Peter’s DEXA data

Take a look at the gap between the timing of that February 2014 DEXA and then the December 2020 DEXA
That’s almost a seven-year gap (Peter isn’t really sure why he went that long between scans)
Nevertheless, he finds it to be super interesting to see the Dec 2020 scan compared to the 2011-2014 data

Total body weight change

Total Body weight only increased 0.8 pounds from 2014 to 2020
One might see this and say “Wow, this guy barely ages. What a beacon of health!”
However, let’s take a closer look started with what changed over those years

Changes to activity level

Peter stopped cycling competitively — no more time trials, etc.
He also had one or two years where he was being “completely aimless and meandering in my exercise” doing everything from bootcamps to running to doing my own workouts
Bu he never stopped exercising and his training volume only went down slightly

So what really fundamentally changed?

The answer is he started doing time-restricted feeding (TRF) and prolonged fasting
From 2014-2016, he was doing a ton of TRF such as OMADs (one meal a day)
Then from 2017-2020 is when introduced fasting protocols From 2017-2018 do a seven day of water-only fast once a quarter By 2019, he changed to three day water-only fasts once per month
From 2017-2018 do a seven day of water-only fast once a quarter
By 2019, he changed to three day water-only fasts once per month

Why did Peter do so much fasting over those years?

There was the belief that the net benefits of fasting made sense
A lot of good things happen when you’re not eating— Our bodies evolved some remarkable mechanisms by which to be efficient with nutrients in their absence And we’re very good at recycling parts We’ve had several podcasts where we talk about autophagy and what happens when nutrients are scarce So the motivation was “this is a really healthy thing to be doing and this is a great part of my longevity toolkit”
To be fair, Peter is not trying to totally discount the benefits of fasting, the point Peter is making is that it’s possible to take a good thing too far
In Peter’s case, he admits that it was hard to notice changes when they are happening subtly especially when using a crude metric like total body weight I.e., “ My scale says it’s all good. My weight hasn’t changed in seven years, that’s got to be good .”
What he needed was better metrics for seeing changes inside his body — this brings us back to the DEXA scan
Our bodies evolved some remarkable mechanisms by which to be efficient with nutrients in their absence
And we’re very good at recycling parts
We’ve had several podcasts where we talk about autophagy and what happens when nutrients are scarce
So the motivation was “this is a really healthy thing to be doing and this is a great part of my longevity toolkit”
I.e., “ My scale says it’s all good. My weight hasn’t changed in seven years, that’s got to be good .”

Peter’s DEXA scan from December 2020

Figure 4.

First thing you’ll notice is total body weight barely budged
The more important change would be his body composition: Fat mass basically DOUBLED from 14.3 pounds to 27.6 pounds (13.3 lb increase) His lean mass dropped from 150 to 137.5 That translated to an increase from 8.4% up to 16.1% in body fat percentage
Fat mass basically DOUBLED from 14.3 pounds to 27.6 pounds (13.3 lb increase)
His lean mass dropped from 150 to 137.5
That translated to an increase from 8.4% up to 16.1% in body fat percentage

Peter’s wake up call

Overall, Peter wasn’t totally shocked that his BF% increased (he could tell he was a little softer)
And to be clear, 16.1% BF for a 47 year old is not high (he was still in the 12th percentile aka leaner that 88% of people that age)
His visceral adipose tissue (VAT) was 113 grams and that is VERY low (3rd percentile)
Peter’s takeaways would be: Definitely have a higher body fat, but this is a healthy body fat VAT is really low which is great But he was a bit confused as to why his body fat was twice what it was before when I was seemingly not eating anything that much and not eating that often
Definitely have a higher body fat, but this is a healthy body fat
VAT is really low which is great
But he was a bit confused as to why his body fat was twice what it was before when I was seemingly not eating anything that much and not eating that often

Here was kind of the wake-up call :

He had never had less muscle in his entire adult life (137.5 lbs of lean mass)
To put this in perspective, even when he was 165 pounds as a wiry little cyclist, he still had 145 pounds of lean mass and only 15.8 pounds of fat mass
Now here he was 7 lbs heavier with LESS lean mass

“That was the aha moment. That was the, ‘What the heck just happened?’” —Peter Attia

ALMI and FFMI from 2014 to 2020:

Now in 2020 his ALMI is 8.8 putting him in the 65th percentile
His ALMI in 2014 was 9.51 (85th percentile)
FFMI in 2020 was 20.7 placing him at the 90th percentile
Remember, Peter is one of those people that’s discordant — he always has a higher percentile for FFMI than ALMI

More about Peter’s nutritional approach during 2015-2020

His fasting was once a quarter, seven days or once a month, three day fast
He was restricting junk food
But he wasn’t deliberately restricting macronutrients of any sort
He was mostly mindful of not eating crap, but he was never really restricting intake
Remember, Peter’s three strategies for energy reduction would be: i) Calorie restriction (CR), ii) dietary restriction (DR), and iii) time-restriction (TR) He was doing lots of CR but he was bracketing it to these windows (fasting) — “ I was going to the most extreme form of CR you could do and doing it periodically ” You could argue there was DR in the form of not having crap food
i) Calorie restriction (CR), ii) dietary restriction (DR), and iii) time-restriction (TR)
He was doing lots of CR but he was bracketing it to these windows (fasting) — “ I was going to the most extreme form of CR you could do and doing it periodically ”
You could argue there was DR in the form of not having crap food

DEXA scan in 2021: shifting focus to adding muscle, high-protein diet, and more strength training [40:00]

Going back to December of 2020…

Peter’s trainer, Beth Lewis , was really riding him about needing to add muscle, “ Dude, we need to bulk you up. You are wasting away .”
And combining Beth’s advice with Peter’s 2020 DEXA results, he decided to shift all of his focus towards putting muscle back on

Three fundamental changes for Peter between Dec 2020 and Feb 2022

1 – He stopped fasting altogether Between December of 2020 and February, 2022, there was not one single day he went without eating
2 – Protein consumption became the only macronutrient in consideration when it came to his nutrition He adopted the goal of hitting one gram per pound of body weight So at the time he’s eating 170 to 180 grams per day spaced out throughout the day to where he’s getting no more than 40 or 50 grams in a single sitting in order to get the maximal utilization in muscle protein synthesis (see AMA #40 ) This basically meant Peter was eating a lot and eating often (at least 2 good sized meals and pure protein snacks mixed in throughout the day) In terms of getting protein in isolation, Peter prefers eating venison jerky , Carnivore Crisps , and pure protein shakes
3 – He added a day of lifting weights (more on this below)
Between December of 2020 and February, 2022, there was not one single day he went without eating
He adopted the goal of hitting one gram per pound of body weight
So at the time he’s eating 170 to 180 grams per day spaced out throughout the day to where he’s getting no more than 40 or 50 grams in a single sitting in order to get the maximal utilization in muscle protein synthesis (see AMA #40 )
This basically meant Peter was eating a lot and eating often (at least 2 good sized meals and pure protein snacks mixed in throughout the day)
In terms of getting protein in isolation, Peter prefers eating venison jerky , Carnivore Crisps , and pure protein shakes

Fast forward to August of 2021 for his next DEXA scan…

Total body weight is up from 172 to 176 (4 lbs)
Lean mass, however, has gone up 7 lbs
Fat mass has gone down 2.5 lbs
Body fat % has actually gone down from 16.1% to 14.1%
He has a bit more VAT but still really low (about the 3rd percentile)
And a “big recovery” on ALMI and FFMI ALMI is back to 9.5 (85th percentile) FFMI is now 21.8 (97th percentile) For Peter, there’s always a discordance there but he considers ALMI to be the more valuable indicator for him
ALMI is back to 9.5 (85th percentile)
FFMI is now 21.8 (97th percentile)
For Peter, there’s always a discordance there but he considers ALMI to be the more valuable indicator for him

More about Peter’s third fundamental change — more lifting

He went from lifting three days a week, Monday, Wednesday, Friday; where each day was a whole body workout
To going four days a week; Monday, Wednesday, Friday, Sunday; where two days upper body, two days lower body
So he increased volume of lifting and he probably even pushed progressive overload even further I.e., greater load, greater sets, greater reps—mixing and matching all those things
I.e., greater load, greater sets, greater reps—mixing and matching all those things

Changes in blood biomarkers?

From 2014 to 2020, Peter was doing a lot of TRF and fasting
During 2020-2021, he dropped fasting and pivoted to focusing on protein intake

Did anything change (good or bad) in terms of his blood biomarkers?

No appreciable change in biomarkers is the short answer
Keep in mind there are certain biomarkers that are now no longer really amenable to measuring change as it pertains to nutrition (For example, lipids) By 2021, Peter is on a maximally suppressive lipid regimen He’s taking a PCSK9 inhibitor and a statin, effectively obliterating his apoB levels There would undoubtedly be some fluctuation in apoB as a result of dietary changes, but it’s not really showing up
And the lipid markers that are a better indicator of fuel partitioning—HDL-C, triglycerides—are not really changing
Free testosterone levels are pretty consistently in the 9 to 11 nanograms per deciliter or 90 to 110 picograms per milliliter
So from a biomarker perspective, things are fine
By 2021, Peter is on a maximally suppressive lipid regimen He’s taking a PCSK9 inhibitor and a statin, effectively obliterating his apoB levels
There would undoubtedly be some fluctuation in apoB as a result of dietary changes, but it’s not really showing up
He’s taking a PCSK9 inhibitor and a statin, effectively obliterating his apoB levels

DEXA scan in early 2022: eating additional calories and adding blood flow restriction (BFR) to his workouts [44:45]

Now looking at the time period between August 2021 and February 2022

Changes Peter made during this window of time:

He’s staying the course in terms of he’s still not fasting, focusing on protein consumption, and he still training a lot
But in the summer of 2021, he added blood flow restriction (BFR) to his workouts (see episode #179 with Jeremy Loenneke )
For nutrition, he really started to eat even more calories with the idea that he’s going to allow himself to gain weight and hope the majority of that will be lean muscle
Then in February 2022, he realizes he’s going to need shoulder surgery the next month (March) So he’s actually now doing prehab for shoulder surgery—still exercising just as hard, but he’s preparing himself to have that surgery
So he’s actually now doing prehab for shoulder surgery—still exercising just as hard, but he’s preparing himself to have that surgery

Prior to surgery, he gets another DEXA scan on 2/10/22

Total body weight: 187 pounds Heaviest he’s been in a long, long time
His lean mass has gone up to 152.9 lbs (increase of 8.5 lbs)
His fat mass increased by about 2 lbs
Even though he’s gained 10 pounds, his body fat % stayed about the same—the reason is, of course, his fat mass and lean mass increased in proportion to each other at the same body fat
Interestingly, his VAT is now up to 500 grams (now a little bit below the 10th percentile) So VAT went from basically being undetectable (3rd percentile) to the 10th percentile Note that Peter’s goal for his patients is for VAT to be at or below the 10th percentile
Peter’s ALMI is 95th to 97th percentile and FFMI is above the 97th line For ALMI and FFMI, he wants to see at or above the 75th percentile
Heaviest he’s been in a long, long time
So VAT went from basically being undetectable (3rd percentile) to the 10th percentile
Note that Peter’s goal for his patients is for VAT to be at or below the 10th percentile
For ALMI and FFMI, he wants to see at or above the 75th percentile

DEXA scan in late 2022: a dramatic change following shoulder surgery, and the impact of stress [48:30]

Shoulder surgery

A month after his February 2020 DEXA scan, Peter has shoulder surgery on March 21st
He entered surgery at about 187 lbs, and by the end of April (one month later), Peter’s body weight dropped down to about 172 lbs — “insanely quick” drop
He was only inactive for a total of two days A couple days after surgery, he was on a stationary bike He was in the gym doing leg workouts and lifting with his left arm So it’s not like he lost that muscle mass because he was bedridden
“This to me was a really sobering wake-up call”
A couple days after surgery, he was on a stationary bike
He was in the gym doing leg workouts and lifting with his left arm
So it’s not like he lost that muscle mass because he was bedridden

Couple of things happened around this time :

1 – This is a confounder here, he got sick right after surgery

The net effect of that bug was it really suppressed his appetite, but also his intense training went down and that has an appetite suppressing effect

2 – But the other big thing that happened was he couldn’t carry heavy things

Couldn’t pick up anything heavy or do a pull-up or do any of these things
Peter regrets that he didn’t get a DXA scan at that time, because he’s really curious as to what it would’ve looked like and it would’ve been a great thing to have compared
But nevertheless, weight gets down to 172 and then he basically just began this “insane recovery of eating”

Additional changes Peter made during the months after his shoulder surgery

Around the summer of 2022, Peter was under more stress than he’s ever felt (discussed on AMA #41 )
Writing his book, Outlive , was a big factor in the stress — “ The irony of writing this book on longevity is killing my longevity ”
At this time, Peter made a conscious decision: His sleep is going to stay good He was not going to sacrifice exercise He’s not going to sacrifice time with family He’s not going to drink more But the one thing he consciously relaxed on was eating — “ I’m going to make zero restrictions on what I eat, like zip and zero. If it’s in front of me and I want to eat it, I’m eating it. There’s no consideration. That was it .”
His sleep is going to stay good
He was not going to sacrifice exercise
He’s not going to sacrifice time with family
He’s not going to drink more
But the one thing he consciously relaxed on was eating — “ I’m going to make zero restrictions on what I eat, like zip and zero. If it’s in front of me and I want to eat it, I’m eating it. There’s no consideration. That was it .”

*Quick question from Nick:

What have you seen with patients who maybe haven’t had surgery and maybe let’s say they don’t work out as much as you, but they are in the gym three days a week. But then summer rolls around and they’re traveling and they aren’t able to work out for two or three weeks. Do you see the same amount of muscle loss in a short period of time, even for people who maybe aren’t at your exercise level?

No, it’s definitely a function of lean mass because remember a lot of that you’re losing is glycogen and water as well
It’s a bit misleading to say we lose that much muscle mass — in the early days of that, it’s a ton of water weight
So the more lean mass you’re starting with, the more you can lose
And the more inactive you are at a baseline, the less of a delta there will be
That said, Peter has a patient who had the identical surgery to him about two months later and he had the exact same experience weight wise Roughly speaking, he lost 10 pounds and he hit his nader six weeks post-op Peter’s not aware of literature that makes that case, but it would be a very interesting topic to look at what’s the average weight loss and then regain in body comp change, status post hip surgery, knee surgery, shoulder surgery, et cetera
Roughly speaking, he lost 10 pounds and he hit his nader six weeks post-op
Peter’s not aware of literature that makes that case, but it would be a very interesting topic to look at what’s the average weight loss and then regain in body comp change, status post hip surgery, knee surgery, shoulder surgery, et cetera

Back to Peter’s temporary “zero restriction” diet

Referring to the months between his March 2022 surgery and his next DEXA scan in December 2022…

Peter says it’s strange to go deep into his own weird psychology
But there’s a part of him that knows that he’s not going to eat this way for the rest of his life, so he made the decision to just enjoy this period of time
And he could really sense the stress eating
For instance, he’d be overwhelmed at his desk with 100s of emails and getting “peppered by book edits”
He could just feel his anxiety rising
In those moments of late-night stress he would would walk down to the pantry and get himself a bowl of mini-wheats and “inhale them”
“It’s sort of funny to think back at what I was doing” says Peter

Figure 5. DEXA from 12/6/22.

DEXA scan results in December 2022

Changes to total body weight:

Nine months post-surgery and six months post weighing 172 pounds, Peter now weighed 196.3 lbs
That is 10 pounds more than he weighed preoperatively (Feb 2022)
And that’s about 23 lbs more than he weighed at his absolute low point post-op

Two pieces of good news:

1 – Of all that 10 pounds that he gained since February, two of them were muscle
2 – His VAT was unchanged (down slightly, but within the margin of error and still under the 10th percentile)

Body comp changes:

Lean mass went up slightly
Fat mass went up a lot (from 27 to 34 lbs)
Body fat increased from 14.4 to 17.4%

Figure 6.

Total body fat as you can see based on age, Peter is now about at the 20th percentile
But here’s what’s interesting: It’s a very fine line to go from where he is now to being at the 50th percentile, which would be about 20 to 21% body fat
Visceral fat, about 500, is at the 10th percentile

Figure 7.

ALMI is like 10.2 kilograms per meter squared is sort of between the 90th and 97th percentile
FFMI was about 23.3 — But as he’s mentioned, in the case of discordance bt ALMI and FFMI, he generally refers to the ALMI

Were you surprised that body fat increased that much but your VAT stayed the same?

It was a pleasant surprise, says Peter, “truthfully, I thought my body fat would be north of 20%. I was very pleasantly surprised that it was only 17%.”
Remember, this is all relative: Peter has patients who live at 25, 30% BF and they’d give anything to be at 17%.
The whole purpose of this discussion was to talk about the trajectory over a decade plus time and how changes in diet, fasting, protein, training and let’s not forget underneath all of this is age
For Peter, “age doesn’t explain what happened in the last six months. Let’s make no mistake about it. The last six months is clearly in an experiment in ‘eat as much as you want and see what happens’.”

Recent blood work for Peter :

Peter was pleasantly surprised at the results
Triglycerides were about 45
Fasting insulin was about 7 – he’d prefer to be a 5 or 6 at the most
His testosterone remains normal at 11 nanograms per deciliter for free testosterone
What about the liver enzymes? Did that go up at all with added fat? They did go up a little bit, but he had switched to a different statin (from Pravastatin to Crestor), so it’s hard for him One of the biggest drawbacks of statins is they’re so commonly interfere with liver enzymes at a low normal level that sometimes it makes it a little bit harder to interpret if there’s anything else going on
They did go up a little bit, but he had switched to a different statin (from Pravastatin to Crestor), so it’s hard for him
One of the biggest drawbacks of statins is they’re so commonly interfere with liver enzymes at a low normal level that sometimes it makes it a little bit harder to interpret if there’s anything else going on

Peter’s nutritional and training approach following his most recent DEXA scan [59:15]

BFR

Peter mentioned earlier that he added blood flow restriction to his training: Does he think BFR has been hugely helpful in gaining more muscle mass?

It does make a difference
If you go back to December of 2020 when Peter was “rock bottom” in terms of his muscle mass, and fast forward to February 2022 … He gained 15 pounds and all of it was muscle Fat mass went from 27.6 down to 27 Lean mass went from 137.5 to 153 Body weight went from 172 to 187 15 pounds up and a little more than 15 of that was lean mass
So how did that happen? That was a lot of training A lot of protein A lot of BFR And he did dial back his zone 2 time from about 4.5 hours per week to 3.5 hours per week (though he probably added some zone 5 time)
He gained 15 pounds and all of it was muscle
Fat mass went from 27.6 down to 27
Lean mass went from 137.5 to 153
Body weight went from 172 to 187
15 pounds up and a little more than 15 of that was lean mass
That was a lot of training
A lot of protein
A lot of BFR
And he did dial back his zone 2 time from about 4.5 hours per week to 3.5 hours per week (though he probably added some zone 5 time)

What is Peter’s plan going forward after his latest DEXA scan in December 2022?

Peter is going to try something nutritionally for the next four months that he’s never done before
Up til now, he has done it all in terms of calorie restriction (CR), dietary restriction (DR), and time-restriction (TR)
Peter has done CR in the extreme version (i.e., 7 day water fasting), but he’s never done straight calorie macro tracking as a form of CR – which is his plan for the next 4 months
Peter sent Layne Norton his latest DEXA results and ask for Layne’s help
Peter’s goal is to lose 10 lbs and have all of it be in the form of fat
Layne’s view is that this is possible if done slow enough and with proper macro tracking

Tracking macros with Carbon app

Peter is going to use the app called Carbon (Layne’s app)
it’s a great database in terms of foods
has a built-in coach
You plug in your body weight, your goal (lose 10 lbs), and the timeframe (4 months), and that you want to preserve muscle mass
The app then spits out calorie targets and it’s asking questions like:
Do you want to be low carb? Low fat? Balanced? Keto?
Peter selected balance and protein as the biggest goal
The app has Peter at 184 grams a day for his protein target
Total calorie goal is about 2700 to 2800 a day
It also gave him fat and carb goals but within the first four days, he realized he was always under his carb goal and over his fat goal (Peter was defaulting to 30% protein, 35% carb, and 35% fat)
Peter just told the app that that’s what was happening and it adjusted it
To be clear, the only thing Peter is paying attention to is calories and protein
He enters my body weight every day and every week the app is making adjustments

Overall, Peter says…

“I’m happy to be doing this is its good for me to have an experience with this because this is one of the three strategic levers that we want to use with our patients”
“I want to be able to say, guys, I have experience with all of them, I can speak to the challenges of them”
And not to be overlooked is how much the technology today is better than it was a long time ago

So your protein hasn’t changed now doing CR compared to six months ago?

It’s the same says Peter
He’s still trying to get 45 to 50 grams of protein four times a day
Breakfast is usually 8 eggs (4 whole, 4 egg whites) with toast and butter
He supplements with a shake comprised of 24 ounces of almond milk, 50 grams of protein, and frozen strawberries
Salad recipe is typically chicken, olive oil and balsamic vinegar (and other veggies)
Dinner is where Peter has the most variability but tracking it in the app is easier than he thought it would be

A rundown of the various nutritional methods of energy restriction [1:06:15]

For more on this, check out AMA #40

3 Nutritional methods of energy restriction

1 – caloric restriction

Which means if you’re consuming 3,000 calories a day right now, we’re going to cut that down to 2,500 calories per day. We’re not going to pay attention to when you eat those calorie
We’re not even really paying attention to what those calories are, but there’s going to be an energy deficit.
So that has the advantage of being agnostic to when you eat and agnostic to what you eat
It has the challenge of being more complicated with monitoring all your intake

2 – dietary restriction

This basically means “make something a bogeyman, and never eat it”
The dietary restriction approach effectively means: we’re going to restrict something but we’re not going to limit when you eat or even explicitly talk about how much you can eat
But by restricting something that you can eat, you’re going to default in to eating less.

3 – The final way is time restricted feeding (TRF)

This means we’re not going to ask you to count how many calories you’re eating and we’re not even going to tell you what not to eat
We’re just going make the window in which you eat narrower and narrower
And if we make that window small enough for most people, they will probably eat less

Pros and cons of each method :

CR is restricting energy deliberately

what’s the advantage of this? the most direct way to solve the problem other advantage is it is the one that is completely agnostic to what you eat and when you eat it
what’s the downside? it requires work, you have to actually do the tracking
the most direct way to solve the problem
other advantage is it is the one that is completely agnostic to what you eat and when you eat it
it requires work, you have to actually do the tracking

When it comes to DR

depending on what you pick to demonize, i.e, whatever you make your boogeyman, that’s going to determine how easy or how hard it is and also how effective it is
the more restrictive the diet, the more likely it is to be effective at reducing energy intake
the danger of DR is its pretty easy to still gain weight, still take on excess energy because you can still overeat through it
it can be somewhat socially restricting depending on what you pick

TR is conceptually the easiest

TR is basically just don’t eat anything outside of your designated eating window
the big drawback is you can really get into a problem pattern around protein Peter he “I can tell you almost without exception, people who go on long-term time restricted feeding, lose insane amounts of muscle mass and they often gain fat mass while their weight goes up or down slightly.”
The other thing, and this is less common, you can still gain weight on time restricted feeding if your window isn’t quite narrow enough or you force yourself to eat a lot during that window
The bigger problem is just poor health choices, poor food choices that leads to poor health, leads to poor muscle mass
Therefore Peter is not a huge proponent of TRF except for patients in whom it’s just the only instructions that they can follow
Peter he “I can tell you almost without exception, people who go on long-term time restricted feeding, lose insane amounts of muscle mass and they often gain fat mass while their weight goes up or down slightly.”

Current thoughts on fasting and key takeaways [1:09:45]

Do you have any plans to incorporate the longer term fasting back in your life?

Peter says possibly but not at the same frequency he used to (for the reasons mentioned above)
For another reason, his schedule and work environment makes it more of a challenge
He’s not traveling to NY and staying alone, he’s mostly home with his family now

Parting thoughts and key takeaways :

Don’t lose sight of the fact that you want to index health over weight
This case study focused heavily on weight, but in it, you’re seeing some of the effects that go beyond that, visceral, fat, lean mass
above all else, the most interesting insight here was how much the effect of fasting, long consistent fasting had on body composition in a negative way

A glib example of looking at things in context:

If the only metric you ever cared about was body weight, you’d be a smoker b/c smokers are going to weigh less — but that’s foolish

The same is true for DEXA

If you only relied on DEXA for your metric of health, that would be insane because you would load yourself up with every possible megadose of anabolic steroids, growth hormone, diuretics

It sounds trite and obvious, but you have to look at this stuff in the broader context of everything you’re doing:

How is your sleep?
Your overall state of your nutrition?
You blood biomarkers?
Your functional metrics look like your VO2 max, your Zone 2, etc.
All these things have to be kind of blended together in your assessment

Selected Links / Related Material

Episode of The Drive about body composition and DEXA scans : #227 – AMA #40: Body composition, protein, time-restricted feeding, fasting, DEXA scans, and more | Peter Attia (peterattiamd.com) [4:00]

Episode of The Drive about bone health : #214 – AMA #37: Bone health—everything you need to know | Peter Attia (peterattiamd.com) [9:30]

Episode of The Drive discussing autophagy and what happens when nutrients are scarce : #114 – Eileen White, Ph.D.: Autophagy, fasting, and promising new cancer therapies | Peter Attia (peterattiamd.com) [29:15]

Episode of The Driver where Peter explains how he spreads his protein out throughout the day : #227 – AMA #40: Body composition, protein, time-restricted feeding, fasting, DEXA scans, and more | Peter Attia (peterattiamd.com) [41:30]

Peter snacks Peter likes : [41:45]

Maui Nui Venison Sticks | (Mauinuivenison.com)
Carnivore Crisps | (carnivorecrips.com)

Episode of The Driver where Peter elaborates how he manages his health even through stressful times of life : #231 – AMA #41: Medicine 3.0, developments in the field of aging, healthy habits in times of stress, and more | Peter Attia (peterattiamd.com) [51:00]

Carbon app for tracking nutrition that Peter is using to track his macronutrient intake : Carbon | (joincarbon.com) [1:02:00]

People Mentioned

Stephen Phinney [22:30]
Jeff Volek [22:30]
Beth Lewis [40:00]
Layne Norton [1:01:30]

Transcript

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