Hey everyone, welcome to the PiaRITIA drive. I'm your host, Peter Atia. The drive is a result of my hunger for optimizing performance, health, longevity, critical thinking, along with a few other obsessions I've gathered along the way. I've spent the last several years working with some of the most successful top performing individuals in the world, and this podcast is my attempt to synthesize what I've learned along the way to help you with a higher quality, more fulfilling life.
If you enjoyed this podcast, you can find more information on today's episode and other topics at piamd.com. Welcome to the inaugural AMA Ask Me Anything, not to be confused with against medical advice. We're getting a lot of really good questions on Twitter and realizing that I didn't have the bandwidth or wherewithal to respond to all of them, especially in such a short period of time or short period of space, rather. Bob Kaplan, who's my head analyst, and I put up a little Ask Me Anything on Twitter post and over the next week we gathered a bunch of questions.
They were amazing questions. We organized them. We got probably over 200. Obviously couldn't address them all in this episode, but we kind of bundled them, and I think in many ways we got through probably half of the intended content that people had asked about.
So in this episode, Bob interviews me. I didn't really look at the questions before spend much time preparing, but I also thought it would be more enjoyable that way. And I will say it went by pretty quick, so I guess we were having fun. Depending on how people like this, I think this is a format that we should probably repeat and maybe we'll do this quarterly depending on what the demand is for it.
And hopefully we can use this as an opportunity to sort of answer specific questions without necessarily dedicating an entire podcast to some of the topics. So without further delay, welcome to AMA number one, and hopefully it's one of many. All right. Hey, Bob.
Peter. Thanks for taking the train down this morning. Absolutely. My pleasure.
What time did you have to get up today? I got up at 3am. Was that because you had to catch the train that early, or was there any other reason you got up a little early? The train was at 5am, so I got a little mini workout in before I got in the train.
I was going to be able to squeeze one in today. So we're going to do a double because we'll workout after this. Very nice. Are you still doing the squat every day?
Yes. Literally squatting every day. So this morning you just wanted to make sure you had some time for squats. Just a little bit of time for squats.
Yeah, just work up to a daily max and get in, get out, get the Uber, jump on the train. Well, I think this is officially the first time you're being introduced by voice, at least to people, though anyone who's been reading Nerds Safari will understand that you are my right hand guy on all things pertaining to logging and being a nerd. You are the head analyst in our practice and also a very close friend and probably one of the people who's had his foot furthest in my butt to be doing a podcast. So if I'm going to do it, I was going to drag you into it.
And I guess this is our first experiment within AMA. I think we probably stuck out a tweet like two weeks ago and how many people asked questions. I feel like there was like three or four hundred questions came in. Yes, definitely over a hundred questions.
So well, I haven't been paying attention to them, which is why I see you in the tweet, but I'm guessing you've aggregated them and I have a feeling I'm going to be hearing them. Yes. I'm going to get to all several hundred questions today, but I did put a bunch of them into buckets so that I'm hoping to cover a lot of ground. I'm all yours.
So let's start with alcohol. It's a little early for that. Yeah, well, it's five o'clock somewhere. So this question, I'm just going to read the whole question, but we'll cover the alcohol.
I think if there were more characters, I know it's a 280 characters now, the 148 used to be. So I think this person got all the characters in. Thoughts on consumption of alcohol, marijuana, are we sleeping enough? Ever tried cold water therapy and a shout out to Iceman Hoff, Wim Hoff.
How can we best enhance brain function? Are we working too hard? Are we too removed from nature? Jesus Christ, I can't remember the first question.
Alcohol, thoughts on consumption of alcohol? Just a little generic. Okay. So I put this into a couple of categories.
The first is just a purely physiologic. What is the effect of the molecule ethanol on the body? And just as I sort of talk about sugar or other things, it's really important to understand that ethanol is a toxin, but of course the dose makes the poison. Now the thing that I think many people forget who are not in the world of toxicology is that there is a probability distribution that drives the impact of a toxin on a population.
There are going to be some people at one end of the spectrum who are largely unimpacted by certain toxins and there are going to be others who are not. So ethanol is no exception to that, just as you know, Tylenol or pure favorite poison could be. So again, Tylenol meaning like even though it's at low doses, very efficacious as an analgesic, at high enough doses, it's hepatotoxic. So start with position one.
I'm not convinced that there is a single benefit to ethanol, the molecule in the human body. So ethanol in its metabolic pathway and it's uniquely metabolized by the liver, one of the byproducts is something called aldehyde, which is a toxin. It really has two, and it's a bit of a oversimplification, but it has two effects. An effect on the liver and then there's an effect on the brain.
The effect on the brain is what people drink alcohol for. It's the buzz. It's the CNS depression that also comes with some euphoria. So it's a bit of a paradox there because ethanol, it's affecting the CNS is that of a GABA agonist and GABA of course being is a non-excitatory or depressing neurotransmitter.
But I think as most people will understand, certainly ethanol can have an excitatory effect. So you've got this brain effect of alcohol, you've got this liver effect. The liver effect is very similar to that of sugar or fructose. They have very similar metabolic pathways, not identical, but also not surprising that they overlap given that fructose is fermented to make ethanol.
So from that standpoint, no benefits to ethanol, but again, different people tolerate it through different amounts. As a general rule, each beverage, and I'm not talking the kind you pour yourself where they're a little longer, a little taller, but an ounce of distilled spirits is about 15 grams of ethanol, an appropriate maybe four ounce glass of wine is also about 15 grams of ethanol, as is a beer, kind of like 10 ounces, 12 ounces, again, depending on the alcohol content. So as a general rule of thumb, each drink is about 15 grams of ethanol. One of the things of a patient asking this question that I'm thinking is, well, what's your liver function right now?
And the best proxy we have for that is the ALT, one of the transaminases. So when I see a patient that's walking around with an ALT that's already at the upper limit of what we consider normal by range today, which I do not consider normal, which is probably 42 on our lab, I consider below 20 normal. I'm always asking the question, do they have fatty liver right now? And if they do, is it more in response to ethanol or is it more in response to fructose?
That said, I have at least two patients that I've taken care of either in the past or currently who consume seemingly unbelievable quantities of ethanol, some of them averaging between eight and 12 drinks a day. And by ultrasound, their livers are normal, by LFTs, their livers are normal, looking at coag studies, every other marker you can look at, their liver function is perfect. And these guys are sort of the genetic outliers who have a remarkable tolerance to alcohol. So the point I'm trying to make here is I want to get a sense of how much harm is coming purely in a hepatic sense from alcohol, and then make sure we're drawing a line well below that.
But the second point is perhaps the bigger point, which is the why. The why are we drinking alcohol? And I say this as a guy who likes alcohol just as much as the next person. But certainly in my life, I started to ask, am I drinking just for the sake of drinking?
Am I drinking because I'm trying to soothe some other issue? Does my drinking lead to a behavior that I'm otherwise not happy about? And in my case, personally, that generally tends to loosening the reins on what I eat. And I don't think I'm unique in that.
I've got many patients that, when confronted, will say the same thing, which is, yeah, ultimately that's the problem with ethanol. You go out, you get a couple of drinks, and things that you otherwise wouldn't eat, you just start eating. So not that this is at all scientific, but my rule of thumb is the following. As a general rule, I want to drink.
If I'm going to drink, it's going to be good alcohol. I'm going to make it purpose-driven drinking. So I don't drink on airplanes because the alcohol sucks. Like I'm not going to just because they're pouring me some half-assed glass of wine.
I'm not going to drink it. But if I want to drink wine, I'm going to drink wine that is exceptional. If I'm going to drink tequila, I'm going to drink tequila that is exceptional. If I'm going to drink beer, it's going to be exceptional.
And because somebody's going to ask, what are my favorites? My favorite wine is Cleo, which is a Spanish blend. And I've been drinking it since 2007. And I've had every bottle from 7 to 14.
And I'm fully expecting that people listening to this are not going to go and start buying Cleo like crazy because sometimes it's hard to find that I'm going to be really pissed off if I can't get it. Tequila, I know everybody raves about 1942, and I think it's good. But the Class A's O del Repasado is absolutely my favorite. It must be consumed neat.
No ice, no lime, no nothing. And my favorite beer, I'm not willing to say what it is because it is so hard to find. And honestly, not to be a selfish prick, but I'm simply not willing to share it with anybody. One of the guys who works for me's part-time job is sourcing it across the United States and Belgium.
So I'm sorry, guys. I'm not going to let on with that. So that's my thoughts on alcohol. Okay.
Any, can I make a follow-up? Please. Okay. So more or less you said there's nothing beneficial.
I'm sure you're going to get. But what about the French paradox? What about red wine? Isn't a glass of red wine, maybe two for men, maybe three, maybe six, depending on who you ask.
Isn't that associated with better health or less cardiovascular disease or more longevity? Yeah. I mean, I think the red wine thing came about through two things that you mentioned. One is the French paradox, which is why the French seem to live a lot longer and they drink more ergo.
It's got to be bad. Of course, I think that to get into that topic in detail would sort of take the rest of our AMA and it really has to do with just a poor understanding of epidemiology. So there are a lot of things that explain the French paradox. They also smoke more.
I don't think that that necessarily means smoking is better. So it probably has a little bit more to do with what they eat than what they drink or don't drink. The other thing that I think has a lot of people with this lingering idea that a glass of red wine today must be healthy. And I want to be clear, I'm not saying a glass of red wine today is harmful.
But I'm saying it's not benefiting your health is the reseritrol story. So reseritrol is a compound that is identified in very small quantities in red wine. And there was one lab in particular at Harvard that many years ago, and I say many years ago, like probably 15 years ago, maybe 10 years ago, David Sinclair's lab had studied this in high concentrations and they showed that it enhanced longevity. And that created like this huge wave of everybody wanting to take reseritrol supplements.
There are two issues with this. The first is even if you believe those data, which I categorically do not and no lab has ever been able to reproduce them. And I'm not even convinced that Sinclair today would believe that those were valid. You would not get that amount of reseritrol in a glass of red wine.
So it's sort of like the, should I be eating more dark chocolate that live longer? Maybe, but you're probably better off just taking cocoa flavonoids if you buy that that's the active ingredient that's going to enhance nitric oxide production. But the one thing I guess I'm glad you asked this follow question because I have some patients who will argue this and honestly, maybe they're right, which is there's some patients who say, look, just a single glass of wine a day helps me unwind a little bit. And isn't there any benefit in that?
And I guess the answer is possibly. And so the question is, does the net benefit of that, which could be a lower amount of cortisol, a lower amount of emotional distress, could those things be beneficial relative to any of the potential drawbacks of ethanol such as increased appetite, dysregulation or I'm not even getting into sort of pathologic behaviors? Maybe one thing I have observed in the aura ring has made it very easy for me to track this is one drink in the evening does not impact my sleep two or more absolutely does and does so in a profound way. The two things that happen are my resting heart rate will be 10 beats higher.
It will take very long for me to reach my resting heart rate. So what you want is your resting heart rate to be achieved within the first third of your sleep cycle. And more importantly, and perhaps more surprising to me is my heart rate variability gets squashed. So I have a very low average heart rate variability.
And I have more than two drinks and even the volatility of my variability is very low. And that is reflected in my sleep. It also definitely compresses REM cycles. So even though when you have a few drinks, you're groggy and you think you're sleeping better, you're just less conscious that you're actually sleeping worse.
Okay, let's move to the next one. Best lab tests, the bucket that I put this one under. So there are a couple of questions at least. One question was, what four to five tests can we go to our PCP or primary care physician and request they run?
Second question, what are the best lab tests as markers for longevity? Well, so the first one is, and I guess you could divide these into things that you really only need to have checked once and then things that maybe you ought to be checking more than once. So a couple of things that everybody needs to have checked once is LP little a and APOE. So LP little a is a phenotype, but it effectively reflects a genotype, the LPA gene.
And we're going to have an entire probably two and a half hour discussion on LP little a, so I'm not going to say anything more about that. But suffice it to say, if you're listening to this and you don't know why I'm suggesting that you will, but everybody needs to know their LP little a preferably their LP little a particle number, but LP little a mass is to a first order a reasonable approximation. APOE of course is a gene and it exists mostly in three forms, the two, the three and the four, there are others, but they're almost, I've never seen one. And because it's a gene you get one from each parent, so therefore you can combine the two, the three, the four into six combinations, two, two, three, two, three, four, three, three, three, four and four.
And it is important to know those in my opinion, though, I will certainly find myself arguing this point with physicians who say, why the hell would you ever want a patient to know that there's nothing you can do about it? Because of course, this gene is probably the second strongest gene to predict Alzheimer's disease by magnitude, but the strongest by far by frequency. In other words, it's the one that matters more at the population level. I would agree with the logic of said physicians if I felt that there was nothing one could do to impact their chances of Alzheimer's disease.
Obviously, I think that that's sort of nonsense. You and I and Dan co-authored a paper with Richard Isaacson at Cornell and a few of his colleagues on Alzheimer's prevention. So obviously in the camp that thinks Alzheimer's disease is at least somewhat, if not significantly preventable and therefore genotyping gives us great insight. Furthermore, a BoE gene of type gives enormous insight into cardiovascular risk, something that we probably ought to do a dedicated discussion around APOB, APOC and APOE, just straight up APOTalk.
I'd like to talk more about that now, but it's probably irrelevant. So you got to know your LP with LA, you got to know your APOE. The other thing that again, I sort of think a lot about is if LP with LA is the single most important lipoprotein, then LDLP or APOB would be the next most important. So that's also something that I really think ought to be tracked.
Boy, we're only allowed five, huh? Because I really, I guess I take for granted that we can just order lots of lab tests. Can you explain, just start back up, when you say LDLP or APOB, I think some people might think like you can get either or test, but they're more or less testing for the same thing. Can you explain how APOB relates to the LDL?
So there's actually two APOBs. There's APOB48, which is an APO lipoprotein that sits on something called the chylomicron, and then there's an APOB100. And there's one and only one APOB on each of the following molecules, VLDL, IDL, LDL, and also LPLA. So by counting the number of APOBs, you are counting the number of LDL particles, but because you measure APOB in mass, it's measured as milligrams per deciliter of APOB versus LDLP is measured in number or nanomole per liter.
So the number will look very different. You know, if I said, tell me your APOB and your LDLB, they will have different units, and therefore not look anything alike, but they're proxies for the same thing. And that of course changes. It's influenced by four things.
It's influenced by the amount of cholesterol you synthesize, the amount of cholesterol or sterile that you reabsorb, the amount of triglycerides you have to carry around, and your clearance of the particles, which is primarily driven by something called the LDL receptor or LDLR that sits on the liver. And because those four factors can all change in response to diet and drugs, to a different extent, obviously triglycerides are by far the most sensitive to nutritional change. LDL receptor, probably the most genetically preset, that there are ways to tweak these things and certainly drugs tweak them. So we've got lots of ways to do that.
But this is an important thing to know. I mean, the four lipoproteins that approximately this order are important is LP, little A, LDLP, small LDL, the subset of LDL that are below some cutoff, typically about 20 nanometers. And then we don't have a way to measure something called the VLDL remnant. So we use the poor man's proxy as I look at VLDL cholesterol, which you take the non-HDL cholesterol and subtract the LDL cholesterol, which you get off a standard lipid panel.
That's especially helpful if at least the LDL is measured directly. But then of course you're often compromising on getting an indirect measure of the non-HDL. So but that probably is a better proxy than taking triglyceride and dividing by five, which is the other poor man's way to get a VLDLC. And I like to see that number less than 15 milligrams per decilier.
Did you just find a utility for total cholesterol test? I have zero utility for total cholesterol. I think the only time a clinician should ever even pay attention to that number is if you have a patient that you are concerned has FH, familial hypercholesterolemia, and you're trying to get them approved for a PCSK9 inhibitor, then you will actually need to know their total cholesterol and their LDL cholesterol because you will use cut offs typically total cholesterol more than 350 LDL cholesterol more than 250 milligrams per deciliter is your cutoff. But I don't pay attention to LDL cholesterol, I don't pay attention to total cholesterol, and I pay minimal attention to HDL cholesterol.
I'm more interested in the ratio of triglyceride to HDL cholesterol. But as we know now, increasing HDL cholesterol pharmacologically does not seem to have any benefit. I'm not even convinced increasing it diaterally does. I think it just goes along for the rock.
In other words, I think that the things in a person's nutrition that increase their HDL are benefiting, but not because of the HDL, the HDL C is going up as a result of it. So I guess after all that rambling, I basically said three things, which is LP, little A, ABOE, LDL P. I think everybody should encounter an oral glucose tolerance test, in particular one that uses insulin as well as glucose. So not uses insulin, but measures insulin.
So you would take a fasting glucose insulin level, you would consume a standardized amount of glucose, typically it's recommended to use 75 or 100 grams of liquid glucose called glucolla. We do that for most of our patients. However, I am now on occasion using normal glucose to challenge them. So 100 grams of glucose in the form of rice or potatoes, because I do think there's a subset of people who you're getting misleading responses from when you're using liquid glucose, which is actually quite unnatural.
You don't consume glucolla regularly? I mean, I didn't look in your fridge. You know, I've got six bottles back there, but I say that only for the special occasions, like along with the other alcohols that I like. Now, the shit is horrible, taken enough of those glucose tolerance tests.
In fact, I'll probably never do one again. I'll probably from now on only do them with rice or potatoes or something like that. Is that complicated to do the OGTT with insulin or is that something that most? Well, it's interesting because I do see some stuff on Twitter about, hey, why do I need to go to my doctor to do that?
I can just do it at home. And you can do it at home with the glucose response because we have portable glucometers, but insulin can't be measured easily. It's not a test you can do at home. So it needs a laboratory.
And if you're not seeing the insulin, you're not knowing the answer. So if you fail a glucose tolerance test on glucose levels, then you've really failed. And what do I define as a failure? I want to see fasting glucose, typically below 90.
I want to see one hour postprandial below 120 to 130 depending on the amount of muscle mass the person has. And I want to see two hour glucose below 100. In other words, I have much more rigorous standards than the laboratory form would show. And you can be there and still have hyperinsulinemia, especially postprandial.
Usually a person there will not have hyperinsulinemia when fasting, but it's not uncommon if I'm seeing a patient tomorrow. I was just looking over his labs today and he's great fasting glucose. Fasting insulin is below six, which is my target. At one hour, his glucose is like 114, great, but his insulin is 56.
And at two hours, he's fine below 100 and his insulin is below 20. So what is the implication there of this guy who's got basically only one X on his record, which is his one hour insulin is 56? Well, that's, you know, as Joseph Kraft describes that, that's diabetes in situ. So that is postprandial hyperinsulinemia, which is a harbinger to insulin resistance.
And look, he might be five years away from being insulin resistant, but that's exactly the time I'd like to be able to intervene. And so this is one of those tests where, yeah, it would be a lot easier if we could just do it at home with our glucometers, but I think it is worth the hassle of doing it and getting the actual insulin data. Boy, what else do I like to see? I've already got pretty heavy focus on the cardiovascular, so I'll try to avoid any other cardiovascular stuff, although I obviously see reactive protein, a homocysteine, or an oxidized LDL or an oxidized phospholipid are really, really helpful.
But I think since we're only going for five, probably ALT, which I alluded to earlier, I think today we're just seeing so much fatty liver disease. And again, the labs, which are basically showing you plus or minus two standard deviations have just seen an upward drift of this over decades. And I was actually just talking about this with Rob Lustig a while ago on another podcast, which I don't know what order we're going to release these things, but either have already come out or be coming out. But we were talking about how we both sort of share this point of view, which is we just kind of ignore the laboratory references on many of these things.
And for ALT, on our lab, up to 42 is normal. If I see a patient walking around at 38, I'm highly alarmed. You made a great point about that, too. Snuck in and listen to that podcast.
Snuck in and listen to some podcasts already? Membership has its benefits. The ALT, so 42, I think you said, is that's considered normal today, but 30, 40, 50 years ago, that was not considered normal. That's right.
Why? I mean, I think Rob would argue, and I would agree, that as we've seen an increase in fructose consumption, it's driving a greater and greater prevalence of NAFLD. This was a condition that wasn't even recognized 20 years ago. If the last data I looked at are any indication by 2025, the combination of the success we've had treating HEPC and the rampant rise in NAFLD means by 2025, this will be the NASH, which is the sort of NASH, NAFLD to NASH, dyserosis, that pathway will be the leading indication for liver transplant in the United States, which is sort of hard to contemplate when you realize that in 2000, less than 1% of liver transplants were for non-alcoholic fatty liver disease.
And I think one of the things about the lab, the reference ranges, is that they're based on the population mean. So 30 to 40 years ago, an ALT, a normal ALT, would be actually considered lower than 42. But because the national average is higher, when you look at a lab test, you're within range, you may be at 42, and you're looking at it and saying, I want it below 20. Yeah.
The other thing I've seen enormous drift on, even just in my very, very brief career on a relative basis, is estradiol levels in men. I mean, I've seen two upward shifts in the range at the same lab over eight years. So men are becoming more and more and more estrogenized. And there are lots of reasons for that which we'll probably talk about on another podcast.
So those are my, I can't even remember my last track, how many labs I recommended, but I think the spirit of the question was, if you're going to be a minimalist, what are you going to do? You got five in there, definitely. Is that covered just in general, or does that also cover the markers for longevity? Do you want to get into like, if you could actually measure some things for longevity, but you really can't in a lab test that you would want to look at?
So if we're talking longevity purely in terms of lifespan, how long, you know, looking at someone's blood, can you get a sense of how long until they're going to die? The way to think about that. So what you're not going to get on a standard blood test is any of the longevity genes. I mean, you can get some of them, but you certainly, ABOE would be one of the longevity genes.
LP, little A would be a longevity gene in inverse. So the lower your LP, little A, the greater your chance of cardiovascular mortality. So the way I really think about longevity in blood is the three things that you're looking for in blood disease-wise are what is this person's risk of atherosclerotic disease? So heart disease or stroke?
What is this person's risk of cancer? What is this person's risk of neurodegenerative disease? So as you mark down those things, you would say, well, cardiovascular disease is largely driven by three things, lipoproteins, inflammation, endothelial dysfunction. How much of that can we see in blood?
Actually a lot. On the lipoprotein side, we can see most of what we want, which is the LP, little A, the LDL, the small LDL, I'm talking particle number, not cholesterol, and the VLDL is alluded to. On the inflammation side, we can see specific and non-specific markers of inflammation. So on the non-specific side, we can see things like fiber antigen, C-reactive protein.
On the specific side, you can see things like ox LDL, LPPLA2, oxfospholipid, those things. Very helpful. Endothelial health is the hardest thing to see, but I include insulin here because I think that insulin is in and of itself actually toxic at high levels to the endothelium. And James O'Keefe just recently was on a paper that looked at cardiovascular health in patients with type 1 diabetes, so that they were able to actually use the insulin doses that people were using as a way to actually assess the impact on the...
I can't remember if it was myocardium or endothelium. You can look at things like homocysteine. We also look at something called asymmetric dimethylarginine or ADMA and S-DMA, which are inhibitors of of nitric oxide synthase. The way I tell patients is the younger you are, the more your blood tells me about your risk of cardiovascular disease.
So a 40-year-old person who otherwise doesn't have some dramatic LP little A through the roof or something crazy, the blood tells me probably 80, 85% of what I need to know. The older a patient gets, the more I would probably rely on things like CT angiograms or even usually by the time they're older a calcium score becomes less relevant. Calcium score can be somewhat helpful in a younger patient, though. But the latest study I saw, which actually just was an editorial that came out two days ago based on a study in one of the atherosclerosis journals, was looking at 50% of patients that had events, had them at the site of non-calcified lesions.
Not a huge vote of confidence for it, why a low calcium score is that helpful. On the cancer side, I think that's really frankly where blood gives us the least insight. Until companies like Grail have fully functioning liquid biopsies where you're looking at, I think Grail is probably looking mostly at RNA and DNA. Other companies have looked at circulating proteins.
But until these liquid biopsies are there, we don't really have much insight into it. Also, virtually every cancer is a result of a somatic mutation, not a germline mutation. So knowing your genotype doesn't really help outside of a few outlier things like racking or lynch. So cancer really comes down to understanding inflammation, which we've already addressed, metabolic health, which again was also part of cardiovascular stuff, though I didn't go into it.
But so for me, minimizing hyperinsulinemia becomes very important. And I suspect we'll probably have an entire discussion on the role of IGF in cancer and IGFP-3, because I think it's actually quite controversial. But that can also provide some insight. And then Alzheimer's disease actually, I think, is more closely related to cardiovascular disease in terms of risk stratification.
So first of all, knowing that patients APOE immediately gives me a bucket to put them in, which is low, medium high risk. I mean, that's, I don't call it that, but that's sort of how you can think about it. And then you look at the other dimensions of it, which is there's a vascular component to that disease, and that basically proxies what you're seeing in cardiovascular risk. So the more you can improve the cardio metabolic profile, the more you can improve that, then there's the metabolic component period, which is kind of like the glucose utilization part.
And that sort of reverts back into all the metabolic stuff you see in cancer. There's an entire thing around toxins, which unfortunately is probably the one that we have the least insight into measuring. And, you know, for very high risk patients, we do refer them to Richard Isaacson's clinic, a Cornell, which is a dedicated high risk clinic. And certainly there, if the cognitive tests warrants it, they'll do lumbar punctures and start to look at CSF for other markers.
But obviously we don't do that. And unfortunately, we don't have too many patients that are cross-moginating over there. I don't want to harp on this one, but I thought it was a good point that you brought up. You touched upon with the insulin and that some people will get a glucose tested every year and they say my glucose is fine.
It's 82 or whatever it is. And, you know, if they assume that their insulin is fine too, because they're clearing their blood sugar and it's 82, can you explain just why you're not, I mean, you're literally not looking at insulin, but insulin could be elevated and you wouldn't know it. Yeah. And usually the person walking around with a fasting glucose of 82 probably doesn't have a very high fasting insulin.
It's the post-prandial stuff you worry about. And then it gets more complicated because you don't have to worry about are you being misled by the test. So I'm sure many people are listening to this who are already aware of this, but I'm sure enough people aren't that it's worth the time. But if you take somebody who's on a ketogenic diet or a very carbohydrate restricted diet, it's more common than not when you do an oral glucose tolerance test on them that they will have this paroxysmal, very elevated glucose, very elevated insulin after being challenged.
So they'll have a low fasting glucose, low fasting insulin. And then you give them the glucose and their glucose and insulin are sky high. I think I may have told the story once on a podcast about a guy I knew who had gone on a little carb diet and everything had gone great and blah, blah, blah. He lost a bunch of weight and got healthier and everything was amazing.
And then his brother who had type one diabetes needed a kidney transplant and he was a match. So they said, well, I've just got a test to make sure you're not diabetic or anything before we take one of your kidneys. They didn't know GTT and he quote unquote failed and he called me at distress and he was like, oh my God, I can't even get my brother kidney. And I said, well, here's the thing.
You got to have him repeat the test and just you got to refeed with 150 grams of carbohydrates, just eat 150 grams of rice potatoes, whatever for about three days leading up to the test. They repeated the test. And then he called me the next time he called me, he was leaving the hospital after the transplant. Everything had gone well.
The other thing with fasting glucose, by the way, that's kind of useless is it's helpful if you're fasting glucose is 150. There's clearly a problem. But I get patients that get very upset or phosphorylated if they're fasting glucose is 105. And I got to tell you, now that I wear a continuous glucose monitor and I know my glucose 24-7, the difference between a fasting glucose of 90 and 105 in the morning is much more a function of my cortisol level than it is anything to do with my insulin sensitivity or anything like that.
So it's important to understand the role that even stress can play on glucose. And that's why I think fasting glucose is directionally interesting, but it's the insulin that gives you the more fine-tuned insight. Okay, this might be jumping around a little bit, but you talked about your continuous glucose monitor. And I think a couple people asked about that because they realized that you have a CGM and you're not diabetic.
Usually even if a CGM people aren't too diabetic because it's what it's typically used for. So we could get into, hey, why do you wear the CGM and then probably a pretty nerdy game of would you rather, which is obviously not the glucose. But let's say like an OGTT with insulin, would you rather see that in a patient or if a patient could have the Dexcom 5 or whatever that latest and greatest is and you knew exactly what they ate for like a month and you could follow those numbers. Are you going to learn more about that patient through one of those tests or the other?
Well, that's a good question. I think that to have CGM data on a patient, and a lot of our patients don't want to wear a CGM, although I think that's going to change with the Dexcom G6. So I started my career using the G5 now. The G5 I love, but I can understand why if you didn't actually have diabetes, that was a bit of a stretch because you're inserting this needle and it was just a bit more involved plus it required calibration twice a day.
Then a company called Libre got bought by Abbott and they had a no calibration one. It got quite popular, but we've used it a lot and I find it to be categorically useless. It's so inaccurate and you can't force a calibration. Also, it doesn't have, it doesn't interact with your phone.
So it's just like useless in that regard. So do those both use a needle in the same place? The Libre is typically inserted on the back of the arm and it was at the time a much easier way to insert the new Dexcom G6, which I don't think is out yet, but I've been lucky enough to have a prototype for a while. The G6 inserts the same way as the Libre.
It's plug and play, it's trivial, it requires, you don't even feel it going in. It's a much smaller needle, it goes in much faster. So you're not the one responsible for the velocity which it goes into. It also doesn't require calibration.
Though you can, I still spot check mine once a day. I've been blown away by the accuracy and it's interfaced with the phone, it's second to none. So it's just, it's amazing. I think in reality, if I had a month of CGM data with accurate food information, that's probably more valuable than the OGTT, even though I'm giving up insulin.
I'm not going to get to see the insulin, but I also get to see a month of someone in their real environment eating the likelihood that I'll miss in that entire month because they're going to probably eat something really bad. And if I can see how they're reacting to that, that's probably pretty good. But look, it's still not a complete substitute for that hyperinsulinemia. So it's not perfect.
But I also find that the CGM for me is one of the, it's along with my sleep ring, it's the stickiest device I've ever used. Whereas any other wearable I've ever used, it's like after two weeks I don't want to wear it anymore because I've already learned what I need to learn. I know how many steps I take, why do I care? So I've got this whole theory around what wearables matter.
It's like, are you measuring something that matters? I don't want to wearable. That's telling me something that's irrelevant clinically is the device actually measuring what it claims to be measuring. Is it am I able to get feedback in real time?
Cause that was the problem with the lead raise. You couldn't get real time feedback, you know, unless you were going to carry around this other device it came with, whereas with the next time you're getting real time feedback. And so as real time as exists, meaning when you eat something, you don't see your glucose move at that moment, but I certainly know after a meal how that meal or the amount of exercise or the amount of stress I was under impacted things. And then do I have an ability to sort of fix it?
Do I have any control over the outcome? So, you know, CGM for me has continues to this day, even though we're probably three years into doing this stuff. I mean, it's hard for me to imagine a day when I'm not going to want to know my glucose every minute of every day. How much of those two things, particularly the CGM, maybe the ring too, because you're talking about a lot of things probably sleep, exercise, diet, et cetera, are these things almost like accountability coaches that the idea that you get this real time feedback of the stuff that you're eating, if you're going to eat some crap, whatever it is, you know that it's going to show up.
Do you think that there's any of that aspect of those things? For me, there definitely is, especially on the glucose ring. I had a buddy stay here last night and like after we went out and grabbed dinner and then on the way home, he's like, oh, do you mind if we stop at the store? I want to get some stuff for the morning and got a little box of granola.
And so, you know, this morning, you know, got up to our thing and he eat some of the granola bit left the box. And as he left, I'm like, God damn it. I love granola, but like it's candy. It's not, it's not, you know, so I just threw it out immediately, like open the thing through the granola out to make sure I wouldn't eat it.
And in part, I think it's that I know that if I eat it, I have to look at my CGM, just go up and it just pisses me off. So it's like, I'm not going to do it. And maybe if I didn't have that CGM, I would have main line that whole box of granola. There's a question in here that I have to get to because it might relate to this.
It's just, how do you think having children has changed you has changed you most? I often think of like, what's at the dinner table and what's left over in terms of your, you know, if you want to call it willpower food that's left over, that might come into play. I mean, I hate to blame my kids for anything, but I'm easily 10 pounds heavier and 10 pounds fatter thanks to them. I think the biggest issue is the food environment.
You know, here in New York, I eat really well because you mean you see my kitchen. The worst thing I'm going to do. Yeah. The worst thing I'm going to do is have a little extra almonds tonight.
Like there's just nothing bad to eat in here. And this is where I'm at my weakest is when I'm in my place. And it's not to say I don't go out and eat a burger and fry sometimes because certainly New York offers more of amazing decadent food than anyplace else. But I think we're most vulnerable in the environment that we eat most.
And you know, for some people, that's work for some people at home, whatever. And so I think that the challenge of having kids, at least for me is that you just have more kid food around and try as you might to say, we're not going to have that kind of stuff in our house. I mean, look, I'm guessing my kids eat better than most kids. You know, I'm juice in the house soda like a couple times a year.
There's like, you know, some Diet Coke after a birthday party or something. But for the most part, it's pretty good. But there's still a bunch of crap. Like, you know, those crackers, wheat thins, my son, who you know very well, he calls them weathins and he freaking loves those things.
Like it's all he wants to eat. And he comes home from daycare and he's like, Daddy, I want some weathins. And I'm like, what? Weathins.
What are you talking about? Weathins. Oh, wheat thins got it. So and I'm not them.
I mean, I don't know if you've had one of those. Yeah, they're freaking awesome. I mean, that's sweet when I was a kid. The texture too.
Yeah. I remember. Yes. There's a period of stack them up, I think, too.
I think yeah. Yeah. You don't need those things one time. I feel like a will Ferrell in the what was that hilarious?
Old school. It's just feels so good when it gets bigger. And then the other thing is there's just like a lot of the times, like if I'm, you know, the kids will want homemade mac and cheese, which is like nowhere near as bad as the crap you get out of a box. But look, it's still mac and cheese.
And if they don't finish it, I still have this immigrant mentality I grew up with, which is like, you don't throw food out, which is horrible. But I was really raised like that was so instilled in me that you don't throw food out. So if my kids don't eat their mac and cheese, I'm like, yeah, I got to eat it. And part of that's just I want to eat it.
But it's like, I really don't want to throw it out. So I'm just as likely to finish off their salmon or steak as I am their, uh, their mac and cheese. So I don't know. I mean, I think the benefits of having kids have probably outweighed that, but that's definitely a drawback of having kids.
So before we leave the lab test, this is technically not a lab test, but I heard you talk about it a lot. And it's something that people probably could do and it might be a good exercise for them. And that is family history. They can tell you a lot about your risk, maybe more so than some markers.
Can you talk about the importance of that a little bit? Yeah, I think it's, I think it's certainly more important than doing a whole genome sequence. So I've had a number of patients, I mean, at least half my patients over the last few years have either done a whole sequence or the very least done, you know, something like 23 and me and we run that through Prometheus. And I'm trying to think of a single time when anything in there altered our treatment plan, uh, beyond what we already knew.
Maybe the odd patient that shows up with a Tom 40 mutation, who was otherwise an 8.0.3.3 that you think, okay, you're probably a little higher risk than we thought for Alzheimer's. So maybe that's one exception. You know, we get some insights into caffeine metabolism, but we almost always know the answer before we, you know, we look for it just based on what they tell us clinically, but the family history is incredible. And a lot of the times you can see things in family history, like you can often spot an elevated LP little a before you get the bloods back, because usually I've done a history and a physical one, a patient before I get their first blood test back.
And it's not uncommon for me to see just a violent streak of heart disease and a family and be like, okay, you're going to have an elevated LP little a there's no two ways about it. And sure enough, they come back in a tie and you could see that their dad had it, their dad's mom had it, their dad's mom's mom had it. And you just sort of, because it's a co dominant inherited gene. So you can see how it rattle through the family.
Certainly also gives you a great insight into cancer and dementia as well. Less I mean, I think dementia is harder because obviously the further you go back, the less long people were living and you don't mention it. But as a general rule, we, we really look for the mosaic and pattern of a person's predicted mortality based on their genes and things will skew it, you know, your parents smoked and you don't smoke and they're getting disease all over the place. It's hard to infer there.
You know, I have a patient whose mom just died very recently from lung cancer, but it was non small cell lung cancer. So, so, you know, what do you do with that? She was a heavy smoker. He's not.
Does that really increases risk? I mean, as you know, we do a staggering amount of work on cancer screening in our patients and you've, you basically are the guy who runs our model on that. And it's actually a cancer by cancer issue. There are some cancers in which, you know, a first degree relative that has it's a big, you know, and sometimes it's not obvious, like the first degree relative that has bladder cancer and what's the relationship to you having prostate cancer or vice versa.
So when we do the cancer screening in particular, we have the patients go back and do an even more detailed double click on their family history of cancer. So yeah, I think family history is probably one of the more important things we get out of the history on a patient. MD selection. I think you've received this question more than once.
How do I find a good doctor? So what is the best way to find a really good primary care physician? Are there specific telltale questions labs I should bring up with respect to the PCP? I think we covered that.
But also to see if they've picked up a medical journal in the last 20 years. You know, I sort of actually had this discussion with a patient Monday who's looking for a concierge, you know, primary care physician since I'm not a PCP. I'm many patients come to me already with a PCP, but sometimes they don't. And they want to have this question.
So, you know, I kind of walked him through my mental model, which is there's no one size fits all here. You just have to decide what it is you need and want. So I think about availability, affability, ability and advocacy as sort of the four broad pillars that you're looking for in a physician. And it's pretty much impossible that you'd find all of those in the same person.
So what do I mean by those things? So advocacy is the physician who's connected and knows how to help you navigate through a storm. When you need to go get a colonoscopy, they know the absolute best endoscopist. And if God forbid, like something comes back with a positive finding, they know exactly the right surgeon and boom, boom, boom.
And not only do they have the roll it, but they know how to help you get through that. They will be your, you know, your advocate in the system. I personally think that's very important. I think many people aren't actually thinking of that, but it's important to sort of ask a doctor explicitly and directly about that ability to me is obviously, I just think that that's the single most important thing.
I mean, in the end, yeah, bedside manners, great. Affability is important, but I'll never take affability over ability. You'd want both. They're not mutually exclusive, but don't be confused.
Don't be confused by affability at the expensive ability. So we'll come back to how maybe how you can assess ability, but that's important. Affability business, like you get along with this person and I think you should be able to get along with your doctor. I mean, I think the days of going to the doctor who talks down to you and is basically preaching a bunch of commandments, you know, it just doesn't make any sense.
Like you just don't want those kind of people around because yeah, in the end, they might be the expert, but if they can't bring you along, then the relationship probably doesn't fit. And if I have a patient in which I feel like I can't bring them along or I don't connect with them, I certainly say to them, look, maybe this isn't working, you know, and in the end, you maybe need somebody different from me who can communicate in a way that you like to be communicated with. Availability is basically our access is like, are you looking for someone that you can call 24 seven and that's when people are looking for concierge docs, that's generally what they're looking for. There are lots of non concierge docs though that still have and within the world of concierge look, you've got like the $30,000 your concierge guys and you've got the $3,000 concierge guys.
And so you also have to be able to think about, okay, well, within that, like, what's the difference between those two? What's worth $27,000 more per year if that's the, and those are literally like that's probably the range that I see in New York for concierge PCP. But I guess the person asking this question is probably thinking mostly about ability. I think, you know, the question included something about how they read a medical journal in the last 20 years.
I mean, that's a good question because so much of what we learn in medical school is pretty much irrelevant by the time we're practicing and the lag between when something becomes a finding and when it becomes mainstream or obvious enough that everybody's doing it, you know, I've seen that number estimated anywhere from 12 to 20 years. So, you know, that seems like a pretty inefficient system. So I think there you just want to talk to your doctor and say, look, how, how busy are you clinically? How much time do you spend reading literature?
And again, I wouldn't use buzzwords like evidence, do you practice evidence based medicine? Because what doctor is going to say no to that question, like it's sort of silly questions, you know, it's like, so it's mostly just trying to inquire about the curiosity of the person, their passion around learning. Because I think in many ways, if you're not learning quite a bit as a doctor, you're probably not practicing great medicine. If you're not sort of trying to get smarter on diagnostics or, you know, advancements in the field, then you're probably stagnant.
And it's not to say that a doctor who's stagnant can't do great work on certain things, but for most people, they don't want to have like six doctors in their life, you know, they sort of you want to go in person. So I think that's how I sort of think about that. Unfortunately, I'm not really a fan of a lot of the labels that people put on. Like, well, I, you know, I practice functional medicine or I'm part of, you know, this organization or that organization.
I just, I don't know. I think in the end, you got to just evaluate the person individually, regardless of those, those features. And I don't know if that answers the question, but I think so. I think one of the things I was thinking about is people will ask people be relatively specific and they'll say, I live in Boise, Idaho.
Do you know a good doctor there? You may or may not know a good doctor there. However, it brings probably brings up the point that if you can get a referral from somebody that you really respect and think is a great doctor and knows their stuff that a referral probably would be pre valuable there too as well. But it's very hard probably to refer somebody if you're in your own practice as a doctor to really vouch for somebody else across the country.
Yeah, I mean, my my ability to do that is if it's going to happen, it's going to be by luck. It's going to be I already have a patient there and they've got a doc who I've entered. Like, you know, I'm patient in Seattle who's got an amazing PCP up there who I won't name now or else he'll get inundated with a million people. But frankly, I think his practice is probably full.
But every time I've had a patient move up to Seattle, it's like that's going to be your doctor because the guy's like he is the epitome of what a great PCP is. And I love reading his notes. I just I love interacting with him and I love that we compliment each other. In other words, there's a whole bunch of things that I do that, you know, look, he sort of knows a little bit about, but he wants to know much more about lipidology and cancer screening and some of the exercise stuff we're doing.
But then there's a bunch of stuff he does that I like his knowledge of, you know, when the patients travel to this part of the country, you got to be aware of this particular parasite that can show up and here's how we're going to vaccinate you against this. And here's how we're going to, you know, you were in that cave in Texas. Well, you're very susceptible to this kind of thing. And just, you know, someone's got like an HSB flair and like he knows all of the tricks.
And so that's probably the easiest way for me to refer people is that I've worked with the doc directly. Going back to the point, though, I don't think people should be afraid of this process taking a while. In other words, if you go down the path and you find somebody and you think this is going to be my doc and, you know, six months in, you don't like him or her, do it again. Keep doing it.
Keep doing it. And a lot of the questions you ask the doctor's reaction to those questions is probably a litmus test. So if you sense that a doctor is put off by a curious patient who's showing up wanting to be actively involved in their health, well, you don't want that doctor. You don't want someone who's intimidated or put off by your interest and obsession and stuff as a patient.
Segue into racing. You got a number of questions on racing. This one stood out to me. I'll just ask it first.
What was the hardest thing for you to learn when you're becoming a driver? I suspect this is racing not when you got your driver's license. Sure. You can answer that one too.
Parallel park. No, I think the hardest thing is something that I still struggle with is. So when you think about driving, like what are the sort of elements of it? The first, I guess, is sort of understanding conceptually what's happening.
You don't have that many inputs when you stop to think about it. You have throttle, you have brake, you have steering, and you have shifting. So you have a clutch and a gearbox. Those are your inputs.
Those are your tactics. You go up and down on those things. Furthermore, you only have four contact points. You have four tires that touch the surface and everything else is in service of those things.
So, and then also in the spirit of fours, there are basically four things that determine how fast you're going to go, which is the tires because they're the contact point, the engine, which provides the power, the chassis, which includes everything from the stiffness of the vehicle to its aerodynamics and it's downforce and then the driver. So you as the driver make up one component of those four things that determines the outcome. You have these four contact points as the tires and you basically have four inputs. So I think the first thing that one has to learn is vision.
Like you have to understand, well, I guess the line slash vision I put together. So there's a, there's obviously a line that a driver takes. If you're watching a race on TV, you're noticing that all of the drivers are driving in the exact same place unless they're overtaking another driver. But there's a optimized fastest way to go around any race course.
And for every circuit that I would drive, either real or in the simulator, I know the line, like insight, like I know exactly where the car needs to be at every moment in time. And I think for some people, that takes longer. For me, that was one of the few things that didn't take long because maybe because I'd already ridden a bike so much, a bicycle and in time trialing where you're on these every second counts, like you learn exactly what, where the apex of a corner is, how to take a corner, all those things. I think that came to me pretty easily in driving.
You have two types of steering issues when you're going around a corner. Obviously cornering is what makes driving hard. It's easy to drive in a straight line really fast. It's hard to drive around a corner really fast.
And the two things that tend to go wrong are understeer and oversteer. So understeer is when the steering wheel is turning more than the wheels are turning. So that means that if you're trying to turn to a corner of the, around the right, your wheels are pointing in a direction that is turning you to the right, but you're drifting to the left. So that's called understeer.
You are steering less than you would like to. That is a relatively easy problem to correct. And it's also a relatively easy problem to see because where you're going is not where you want to be going. And that is almost always the result of too much speed.
And again, for every situation, if you decide are you backing off the throttle, if you're on throttle, you're actually applying brake, et cetera. Oversteer is the opposite of that. Oversteer is the back end of the car is starting to come out from behind you faster than you want it to. So that means the car is now going to turn faster than the rate at which you've asked the wheels, the front wheels to turn.
Now, I think learning to correct an oversteer is for me the greatest learning curve because it's not something for which the initial cue is visual. It's actually something you feel. You feel oversteer in your butt because it's basically your butt and the seat are starting to go in a direction that you don't want to go. And there's a well understood way to correct an oversteer, but it's well understood conceptually.
It's not necessarily intuitive. The first step of correcting an oversteer is intuitive, which is changing the angle of the wheel, the front of the car. It's the pause and the correction that comes after that is it's like, and I got positive that there are many drivers out there for whom this was a trivial exercise to learn, but for me, it was not. And in fact, one of the things that my coach had me do was he was like, you just got to get comfortable going sideways.
And so he sent me off to a sprint car school, you know, sprint cars are those huge wheels in the back, little wheels in the front, very small cars in terms of weight and staggeringly overpowered. But you're basically driving that car sideways. You're drifting the whole way. I was like, Hey, should I go to drift school?
And he's like, no, no, no, go sprint car. I mean, that's that's where you'll really learn the stuff. I think the other thing that was hard to learn, although I'm so much better at it now that it's, I mean, not the same good at it, but I'm so much better than where I started is understanding how to modulate, you know, a one out of 10 response on the throttle and the brake when you're driving on the street, you're not really thinking of that stuff. You're on the gas.
You're not on the gas. You're on the brake. You're not on the brake. But in a race car, even how you come off the brake pedal, you know, if you're at a five out of 10 brake, do you go five, four, three, two, one or five, three, one off?
And those will produce, especially at, you know, high speeds and with turns, that will produce a very different sensation in one of those you're flipping the car around and the other one you're driving quickly through the line. And so learning how to modulate throttle and brake pressure and making those as smooth and elegant as possible, you know, that that took some time. Sounds like playing an instrument, not that I play an instrument, but if I were to play an instrument, well, you probably have to know those things. Yeah, I don't play an instrument either.
So I can't speak to it. But so on the on the oversteer, just because I'm curious. I always think of left turns as a NASCAR, maybe just in my head when I'm thinking of turning. So if you're doing the oversteer and you're butt sticking out to the back side is moving out to the right.
So you're oversteering. I mean, you're oversteering and you're moving too far to the left. How do you correct that? So the first thing you do to correct an oversteer, if you're in that situation is you actually jerk the steering wheel to the right to flip the front of the car.
And then you're basically going to pause for a moment and let it correct and then come back on the throttle and pick it around. And so when you watch, look at, you know, there's a guy named Chris Harris. There's lots of guys online that, you know, are great to watch. But Chris Harris is one of my favorite drivers.
And he's like a drifting machine. I mean, this guy, he's really got it down. But if you want to be able to drift a car, you basically have to put the car into an oversteer and then hold it there for a long period of time. So one of my favorite videos is Chris Harris drifting one of the 911 GT3 991.
So of course, maybe we'll find the video and link it to people. But it's a he's test driving like the first generation of the GT3 RS. This is probably like 2015. And he's, I think he's at the Porsche circuit.
And there's this one turn where it's like one of the most beautiful examples of a controlled oversteer drifting around. And it's one of those things when if you watch it and you're not a driver, they make it look really easy. When I watch it, I'm just going, God damn it. How does he do that?
Like, because I'm actually watching the micro adjustments of his hand. And I'm like, he is so talented. I will spend the rest of my life trying to become half that good. Speaking of talent, one of the questions is just comment on the reasons you are a great fan of Senna.
You know, I mean, I think I have done Senna is probably considered by many people to be the greatest race car driver ever. He died, of course, quite tragically and quite visibly on May 1st, 1994 at Imola in Italy in an accident that is to this day still debated as to the cause of it, though I have very strong point of view on what the cause of the accident was. You know, I think on many levels, one, he was just so naturally gifted. I was talking actually with one of my patients the other day and he was telling me a funny story about how he, I don't remember the connection.
It was like his girlfriend's brother or something like that. You know, grew up in the UK was, you know, like a guy like me, like not a, not a professional driver, but a guy who really took his driving seriously and had spent years and years trying to hone this craft. And one day he's at a track and he finally lets off his absolute fastest lap of his life in this car on this track. And this was back in 1980 and there was this kid there and they were like, hey, can this kid go take your car around for a spin?
You know, he's never been on this track before. He's never been in your car before. And he said, yeah, okay, whatever. So the kid goes out and went six seconds faster than he had just gone and smashed like, which was then faster than anyone had ever driven any, you know, that type of a car on that circuit.
And of course, the kid was a Senate. So there's just this raw natural talent. The other thing I think is just this incredible passion. You know, there are some drivers like Schumacher who you could, you could equally make a case would be as great a driver and certainly by number of championships will be the greatest driver, but you know, had a much less emotional way of going about things.
I also think just what Senna stood for both, you know, on and off the track. I mean, I think many people were not even aware of how much he cared about Brazil and the people of Brazil until after his death when people realized how much of his enormous wealth he had contributed to, you know, fighting poverty in Brazil. And to this day, the Center Foundation is kind of a remarkable organization there. I'm constantly moved by the response that anyone from Brazil has the center.
Our nanny is Brazilian. And I don't even think she was alive when Senna was, when Senna died. But I mean, she knows everything about Senna. We talk about Senna all day long.
My son's name is Arthan. So, you know, she just loves taking care of little airy. We I was in a I was in an Uber two weeks ago in San Francisco and, you know, the guy had a Brazilian flag all over the car and blah, blah, blah. And of course we got talking and he started asking me about this.
And then five minutes into the discussion, he goes, wow, you're really a Senna fan. And I was like, yeah, I mean, that's all we talked about the whole way to the airport. So, you know, that you could still find, you know, something to talk about with so many people, it's sort of amazing. And I think many people look back at the era that Senna raised as the golden era of Formula One, because it wasn't just that you had Senna.
It was that you had Prosst, you had Mansoul, you had PK, I mean, you had amazing drivers in an era where the drivers mattered more than they matter today. And that's not to take anything away from Hamilton or Vettel or, you know, any of the great drivers today. And those two are amazing drivers. I think Lewis Hamilton is probably the best driver today, but the cars are so much better today than back then, so much safer.
They have so much more downforce back in the late 80s and early 90s. I mean, you were basically riding on mechanical grip alone. And when you look at videos of these guys driving, you know, there's just amazing things. And then of course, there's like, I think it was 93.
There's this very famous lap that I think was at Donington, where Senna started in the four position, meaning so he was fourth on the grid. And so didn't have a very good qualifying. And by the end of the first lap, he was in first that we should also link to that. Yeah, that's like, you'll never see that again.
That was sort of considered the greatest lap in the history of motorsport. Of course, the other thing that I think is amazing is his qualifying time in Monaco in 80, maybe 89, maybe 88, where he qualified about a second and a half faster than Prost and Monaco is a short, fast circuit on the longest circuit. You could never see a second and a half difference when you see, so, you know, in racing, we measure things on the qualifying lap. They're measured to a thousandth of a second for a reason.
There's a reason it's not to the 10th of a second, you know, because the difference between 49, 4, 7 and 49, 4, 9 is pretty big. And those are otherwise both B49 and 5. But when you're qualifying ahead of a four time world champion, which Prost was a second and a half faster, you're just playing a different game than everybody else. You know, Senna won three world titles, although I will always maintain that he won four because in 89, he was disqualified in the final race in Japan for reasons that I think are completely political and completely bullshit.
So as far as I'm concerned, his disqualification was nonsense. And Senna died as a four time champion. I'm convinced that he not died in 94. He would have won the world championship that year, no question, even though it was the Williams 15 card that they were in was having trouble.
But the fact that Graham Hill almost won Damon Hill, the fact that Damon Hill almost won that year as the number two driver tells me that Senna would have absolutely won and probably would have been incredibly competitive next year. So, you know, it's not a night. I mean, you know, he could have easily had those seven world championships that Schumacher had, but yeah, he'll just forever sort of be my favorite. And I love like, I mean, if anyone has anyone's watching this and is even remotely interested in this stuff and they haven't seen the documentary, Senna, it's such a beautiful.
I was going to ask if that would be the one that you would recommend. Yeah. Yeah. Yeah.
For sure. Another racing question. This is a simulator question. How does I racing improve your real world racing skills and could you do more official races or races with fans also favorite car?
So I racing is a software program, which you run in a simulator. You don't need a simulator to run it. You can probably just run it off your PC and play with like, you know, toys. But in a simulator, it's really designed for a simulator because of how high end it is.
I think that I racing is good for every element of driving, but it does have a couple of drawbacks. The first is we were talking about oversteer earlier. And you'll remember that I said that oversteer is not as visual as understeer and that oversteer is something you first feel. The simulator can't really capture that.
So when I'm in a car and I oversteer, it's much harder to correct in I racing because I lose the warning. I only know it's happening when I actually see that I'm spinning. So it's not that it can't be corrected. It's just it's harder.
So it throws your timing off a little bit and what your correction looks like. The other thing that, you know, obviously a simulator doesn't do compared to being in the real car is you don't have the same physiologic stress. So I probably have more seat time at a course called button willow because it's relatively close, meaning it's only like four hours away, but it's in Baker's Field. And I like to go in the summer because nobody else likes to go in the summer.
I can't understand why. And it's hard. I mean, it's, you know, you're in a fire suit inside of a closed cockpit car. When the temperature in the shade is 108 degrees Fahrenheit, it's probably 130 in the car.
You know, it's like the little stuff like what do you do when you can't keep the sweat out of your eyes? What do you do when your core body temperature is two degrees higher? And and what do you do when the dust is blowing in and blah, blah, blah? Like, you know, so you can't, that's just to be able to concentrate through that takes practice and you don't get that practice in the simulator, though.
I do like, I'll wear my helmet in the simulator and do it in a room that's hot and try to like mimic some of that stuff where the simulator is incredible. Is just economics of it. You know, every day you're in a race car on a track, it's thousands of dollars. You know, it's just, you know, unless you're incredibly wealthy, like, it's it's cost prohibitive to really learn how to drive a car well in a car.
It's just like pilots spend most of their time in simulators long before they're up in the air. It's the same thing. And so when I want to learn a new car or learn a new circuit, I want to get a few hundred hours of that on the simulator before I go there and it makes the experience much richer. And if I don't have that luxury, for example, button willow is not in eye racing.
So the first time I drove button willow, I ended up having to watch tens of hours of onboard film in of drivers driving button willow. And even that just couldn't prepare me for it the way driving in the simulator could as far as my favorite car in the simulator, it really depends on what I'm what it's I'm trying to scratch. If I'm trying to go as fast as possible, it's the Pro Mazda, which is not the fastest car in there, but obviously formula cars are much faster than closed wheel cars. And you know, they do have a Formula One car in there.