#411 ‒ AMA #90: Strong convictions, loosely held: how Peter's views on fasting, keto, metformin, rapamycin, whole-body MRI, and exercise have changed

Hey everyone, welcome to a sneak peek, ask me anything or AMA episode of the drive podcast. I'm your host, Peter Atiyah. At the end of this short episode, I'll explain how you can access the AMA episodes in full, along with a ton of other membership benefits we've created. Or you can learn more now by going to peteratiyahmd.com forward slash subscribe. So without further delay, here's today's sneak peek of the ask me anything episode. Welcome to ask me anything episode number 90. In today's AMA, we're reflecting back on the first 400 episodes of the drive with another episode of the strong convictions loosely held theme. So what are we going to do today? We're going to talk about the drive. a ketogenic diet because I had already lost most of the weight I was trying to lose just from carbohydrate restriction. But when I see people who are successful on ketogenic diets, they often report that they feel quite satiated. And I think that has to do with the type of foods that they're consuming, which satiate them more than carbohydrates. And I also believe there's something to be said for when you are oxidizing fatty acids, that in and of itself is providing fuel endogenously, which is happening obviously during a period of weight loss. So it's a subtle point, but it's worth making because it does reflect a change in my viewpoint, which is that the metabolic dysfunction, the visceral fat accumulation, the ectopic fat accumulation, the insulin sensitivity deteriorating, all of these things are the result of the energy imbalance and hyperinsulinemia is for the ride. But if you magically address the hyperinsulinemia without addressing the energy imbalance, you're not going to fix these problems. And the easiest way to see that is to watch a person who's on a ketogenic diet, who for whatever reason is still in energy imbalance. So they're still going to have lower levels of insulin, but they're not going to lose weight and they could even gain weight. So you could gain weight on a ketogenic diet if you're out of energy balance. So that's sort of the long and short of my views on that. As a result, I think it's made me less, I mean, much less dogmatic about the strategy or the tactics that a person employs when it comes to reducing energy intake. I really don't have a strong preference when a patient is at a point where they need to reduce intake. Once a few principles are met, and we've obviously talked a lot about those things, right? I really am pretty adamant about people maintaining the right amount of protein. And at a minimum, I want them hitting 1.4 grams per kilogram. Of body weight. But if they can accomplish that on a ketogenic diet, on a low fat diet, on a mostly pescatarian diet, I mean, again, it just doesn't really matter as much to me as it once did. So yeah, I think that's probably a big point around the sort of my previous dogmatism around nutrition. And now looking at extended fasting, do you want to talk about kind of what was your initial motivation there and where you're thinking as a bulb? Yeah. I mean, I think it's sort of similar. Again, a lot of things with me begin from a place internally, right? Where I'm doing something and I'm trying to push the boundaries of it personally. So for about a three year period of time, I was doing a quarterly fast and it would be anywhere from seven to 10 days once a quarter. And then on the other two months of the quarter, I would do a three day fast. And what was my logic for this? I mean, to be clear, I would do a three day fast. And then on the other two months of the quarter, I would do a I was not trying to lose weight. I was at a weight that was perfectly reasonable, but I was really fascinated by this idea that with enough nutrient deprivation, we could promote enough autophagy that it would have real health benefits. And just to remind folks what autophagy is, autophagy is the process by which cells break down and recycle old intracellular proteins and structures. So the name autophagy eating, it's literally cells that are eating themselves. And this is a very important process, obviously long, long conserved in evolution, because when nutrients are scarce, the body has to basically reuse and recycle things. Now, the benefit of this, of course, is that what is the body going to do when it needs to reuse and recycle things? It's not going to start with the best stuff. It's going to start with the worst stuff. So if you have cells that are heading towards senescence, if you have cells that are heading towards, hey, that's where we're going to start. Those are the cells we're going to get rid of and recycle for their constitutive components. And again, in preclinical models, extended fasting clearly does this. So there's little doubt that extended fasting promotes autophagy. As a little aside, Nick, and I haven't looked at the literature on this in a couple of years, so maybe what I'm saying, someone will say, no, Peter, we actually, you know, look at so-and-so study. But it wasn't really clear how many days of fasting were necessary to get in to, quote, high autophagy. Because autophagy is not digital, it's analog. It's not like you have no autophagy and then you cross a threshold and now you have autophagy in a digital switch. It's sort of ramps up, kind of like ketosis. Now, in ketosis, we have a threshold we use. It's about somewhere between 0.5 and 1 millimole resting or fasting. We don't even have a unit of measure in autophagy to do that. But having spoken with, you know, the experts on this subject, I think it's and looking at preclinical data, somewhere around three days seemed to be where you could really sort of juice autophagy levels beyond what you would get from exercise or other things like that. Okay. So then the question becomes, well, why aren't you doing that still, Peter? And again, I think there were several reasons for that. But I think what changed most was kind of the evidence, but also the cost. Thank you for listening to today's Sneak Peek AM. episode of The Drive. If you're interested in hearing the complete version of this AMA, you'll want to become a premium member. It's extremely important to me to provide all of this content without relying on paid ads. To do this, our work is made entirely possible by our members. And in return, we offer exclusive member-only content and benefits above and beyond what is available for free. 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