The Peter Attia Drive

• Lower back pain: causes, treatment, and prevention of lower back injuries and pain | Stuart McGill, Ph.D. (#287 rebroadcast)

  View the Show Notes Page for This Episode Become a Member to Receive Exclusive Content Sign Up to Receive Peter’s Weekly Newsletter Stuart McGill is a distinguished professor emeritus at the University of Waterloo and the chief scientific officer at Backfitpro where he specializes in evaluating complex cases of lower back pain from across the globe. In this episode, Stuart engages in a deep exploration of lower back pain, starting with the anatomy of the lower back, the workings of the spine, the pathophysiology of back pain, and areas of vulnerability. He challenges the concept of nonspecific back pain, emphasizing the importance of finding a causal relationship between injury and pain. Stuart highlights compelling case studies of the successful treatment of complex cases of lower back pain, reinforcing his conviction that nobody needs to suffer endlessly. He also covers the importance of strength and stability, shares his favorite exercises to prescribe to patients, and provides invaluable advice for maintaining a healthy spine. We discuss: Peter’s experience with debilitating back pain [3:00]; Anatomy of the back: spine, discs, facet joints, and common pain points [14:15]; Lower back injuries and pain: acute vs. chronic, impact of disc damage, microfractures, and more [24:30]; Why the majority of back injuries happen around the L4, L5, and S1 joints [30:45]; How the spine responds to forces like bending and loading, and how it adapts to different athletic activities [36:00]; The pathology of bulging discs [43:00]; The pathophysiology of Peter’s back pain, injuries from excessive loading, immune response to back injuries, muscle relaxers, and more [45:45]; The three most important exercises Stuart prescribes, how he assesses patients, and the importance of tailored exercises based on individual needs and body types [56:00]; The significance of strength and stability in preventing injuries and preserving longevity [1:08:00]; Stuart’s take on squats and deadlifting: potential risks, alternatives, and importance of correct movement patterns [1:19:15]; Helping patients with psychological trauma from lower back pain by empowering them with the understanding of the mechanical aspects of their pain [1:29:45]; Empowering patients through education and understanding of their pain through Stuart’s clinic and work through BackFitPro [1:38:30]; When surgical interventions may be appropriate, and “virtual surgery” as an alternative [1:46:30]; Weakness, nerve pain, and stenosis: treatments, surgical considerations, and more [1:55:15]; Tarlov cysts: treatment and surgical considerations [2:00:00]; The evolution of patient assessments and the limitations of MRI [2:02:00]; Pain relief related to stiffness and muscle bulk through training [2:06:45]; Advice for the young person on how to keep a healthy spine [2:14:00]; Resources for individuals dealing with lower back pain [2:25:15]; and More. Connect With Peter on Twitter, Instagram, Facebook and YouTube

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• #362 ‒ Understanding anxiety: defining, assessing, and treating health anxiety, OCD, and the spectrum of anxiety disorders | Josh Spitalnick, Ph.D., A.B.P.P.

  View the Show Notes Page for This Episode Become a Member to Receive Exclusive Content Sign Up to Receive Peter’s Weekly Newsletter Josh Spitalnick is a clinical and research psychologist with expertise in treating a variety of anxiety conditions with cognitive-behavioral therapy (CBT) and other evidence-based approaches. In this episode, Josh unpacks the four layers of anxiety—psychological, emotional, cognitive, and behavioral—highlighting why avoidance is the key feature that transforms ordinary worry into disorder. He explains why he continues to treat OCD and PTSD as anxiety conditions despite their DSM-5 reclassification, and he draws important distinctions between worries versus worrying and thoughts versus thinking. The discussion explores health anxiety, illness anxiety, and the impact of modern contributors such as wearables, social media, and the COVID era, while weaving in real-world case studies and Josh’s structured assessment approach. Josh also breaks down evidence-based treatments, from exposure therapy and cognitive-behavioral therapy (CBT) to acceptance and commitment therapy (ACT), along with the role of medication, lifestyle factors, and how shifting from avoidance to committed action can build long-term resilience. We discuss: Josh’s professional background and his holistic approach to treating anxiety [3:00]; Definition of anxiety and changes in the DSM-5 [5:00]; The psychological and cognitive aspects of anxiety [10:45]; Breaking down anxiety symptoms: triggers, fears, and hidden mental rituals [17:00]; Thoughts versus thinking and worries versus worrying: what constitutes dysfunction [20:15]; Health anxiety and the limits of medical reassurance: understanding illness anxiety and somatic symptom disorder [24:30]; Triggering events for health anxiety, symptom fixation, heritability, and the role of nature versus nurture [36:30]; Historical and modern shifts in health anxiety, from HIV/AIDS in the 1980s to today’s heightened fears of cancer [45:30]; Modern factors and recent events that have amplified societal anxiety levels [47:15]; Josh’s approach to patients with excessive health-related rituals and/or OCD using CBT and exposure therapy [54:30]; Hypothetical example of treating a person with a fear of flying: assessment, panic disorder, and the role of medication and exposure therapy [1:03:15]; The four types of exposure therapy and the shift from habituation to inhibitory learning [1:14:00]; Treating people with OCD that manifests in disturbing and intrusive thoughts, and why therapy focuses on values over reassurance [1:21:00]; Acceptance and commitment therapy (ACT): reorienting patients toward values-driven living rather than symptom elimination [1:31:45]; Mindfulness as a tool to cultivate presence, awareness, and healthy engagement with life [1:36:30]; Hallmarks of successful therapy and red-flags that therapy is not going well [1:38:15]; The relationship between anxiety and substance use, and the therapeutic challenges it creates [1:44:45]; Anxiety’s overlap with ADHD, OCD, autism, and physical health conditions [1:49:45]; Debunking the harmful myth that health anxiety is a “made up” condition [1:51:30]; Prevalence, severity, and evolving treatments for health anxiety and OCD [1:54:45]; Treating health anxiety is about providing patients with skills to improve quality of life—a discussion on how to address symptoms often attributed to long COVID [2:01:30]; Balancing the benefits of abundant health information with the risks of fueling health anxiety [2:06:30]; Advice for finding a telehealth provider with expertise in health anxiety [2:11:00]; and More. Connect With Peter on Twitter, Instagram, Facebook and YouTube

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• #361 - AMA #74: Sugar and sugar substitutes: weight control, metabolic effects, and health trade-offs

  View the Show Notes Page for This Episode Become a Member to Receive Exclusive Content Sign Up to Receive Peter’s Weekly Newsletter In this “Ask Me Anything” (AMA) episode, Peter explains how to evaluate sugar and its substitutes in the context of health. Peter explores the role of sweeteners in three common use-cases – beverages, protein supplements, and sweet treats – and breaks down how our evolutionary craving for sweetness now clashes with today’s food environment. He examines whether sugar is uniquely fattening, the hormonal effects of sugar consumption, and the significance of timing in sugar intake. The episode compares natural versus refined sugars, sugar in beverages versus in solid foods, and the pros and cons of popular sweeteners including saccharin, aspartame, sucralose, allulose, and sugar alcohols like erythritol and xylitol. With a focus on weight management, glycemic impact, gut health, and long-term safety, this episode offers a comprehensive guide to navigating the sweetener landscape with clarity and nuance. If you’re not a subscriber and are listening on a podcast player, you’ll only be able to hear a preview of the AMA. If you’re a subscriber, you can now listen to this full episode on your private RSS feed or our website at the AMA #74 show notes page. If you are not a subscriber, you can learn more about the subscriber benefits here. We discuss: A quick tangent on chess and parenting [2:30]; Overview of key scenarios for evaluating sugar and sweeteners [6:15]; Why humans are hardwired to crave sweetness [13:30]; Evaluating whether sugar is uniquely fattening or more harmful than other macronutrients under isocaloric conditions [15:15]; Why sugar drives appetite: low satiety, insulin response, and reward system activation [18:45]; How sugar type, liquid vs. solid form, and processing level influence appetite and metabolic impact [20:15]; Addressing the common belief that natural sugars are healthier than refined sugars [26:00]; How the timing of sugar consumption alters the body’s metabolic response [29:15]; How Peter advises patients on sugar intake, factoring in metabolic health, insulin sensitivity, and activity level [34:45]; The most common sugar substitutes, their sweetness relative to sugar, and their caloric content [36:30]; Evaluating the role of sugar substitutes in weight control: efficacy vs. effectiveness and limitations in study design [40:15]; Assessing the real-world impact of sugar substitutes on weight, and the role of sweetness without calories [44:00]; The impact of sugar substitutes on glycemic control [47:30]; Are microbiome changes from artificial sweeteners substantial enough to cause obesity and diabetes? [50:30]; How Peter advises patients on the use of sugar substitutes across different contexts [52:30]; Allulose—a sweetener with unique satiety and glycemic benefits and potential for weight control [57:15]; Emerging evidence that stevia, monk fruit, and sugar alcohols may provide modest metabolic benefits compared to sugar [1:03:00]; Sugar alcohols explained [1:04:15]; Sugar alcohols and GI issues [1:05:00]; Xylitol’s dental health benefits and considerations for use [1:06:30]; Artificial sweeteners and cancer risk: evaluating evidence, the aspartame controversy, and the role of dose in toxicology [1:07:15]; Sugar substitutes and cardiovascular disease: assessing flawed studies and the absence of direct risk evidence [1:11:00]; Why artificial sweeteners seem to attract so many negative headlines [1:12:45]; Balancing benefits and risks of sugar substitutes: guidance for desserts, beverages, and protein products [1:14:15]; and More. Connect With Peter on Twitter, Instagram, Facebook and YouTube

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• #360 ‒ How to change your habits: why they form and how to build or break them | Charles Duhigg, M.B.A

  View the Show Notes Page for This Episode Become a Member to Receive Exclusive Content Sign Up to Receive Peter’s Weekly Newsletter Charles Duhigg is a Pulitzer Prize-winning journalist and best-selling author known for distilling complex neuroscience and psychology into practical strategies for behavior change, performance, and decision-making. In this episode, Charles explores the neuroscience behind habit formation, including how cue-routine-reward loops drive nearly half of our daily actions and why positive reinforcement is far more effective than punishment. He explains how institutions like the military and Alcoholics Anonymous engineer environments to change behavior at scale, as well as discussing the limits of willpower and how to preserve it by shaping context. The conversation also covers the real timeline of habit formation, how to teach better habits to kids, the role of failure and self-compassion in lasting change, and the power of social accountability. Charles further discusses how cognitive routines enhance productivity and creativity, how to gamify long-term goals through immediate rewards, why identity and purpose are often the strongest forces behind sustainable behavior change, and the potential of AI to power habit change. We discuss: How Charles’s background in journalism and personal experiences led to his interest in habit formation [3:15]; The science behind reinforcement: why positive rewards outperform punishment in habit formation [10:15]; How the military uses habit science to train soldiers using cues, routines, and rewards [17:15]; Methods for creating good habits and eliminating bad ones: environmental control, small wins, rewards-based motivation, and more [24:00]; How parents can teach kids to build habits and strengthen willpower [32:15]; How adults experience changes in motivation and cue effectiveness over time, and why willpower must be managed like a finite resource [34:30]; Keys to successful habit change: planning for relapse, learning from failure, and leveraging social support [38:00]; Advice for parents: praise effort, model habits, and normalize failure [47:45]; The time required for making or breaking a habit [50:45]; The different strategies for creating new habits vs. changing existing ones, and the crucial role of cues and reward timing [55:15]; How to create habits around long-term goals when the rewards are delayed (like saving money) [1:01:45]; How to stick with good habits that offer no immediate reward: designing reinforcements and identity-based motivation [1:11:15]; The potential for AI to provide social reinforcement [1:16:45]; Mental habits: how thought patterns and contemplative routines shape deep thinking, innovation, and high-stakes performance [1:23:30]; How cognitive routines boost productivity and habit formation but may stifle creativity [1:35:15]; Contemplative routines: using stillness to unlock deeper productivity and creativity [1:40:45]; How habits reduce decision fatigue and enable deep, high-quality productivity [1:44:15]; New research that reveals the power of environment and social feedback in habit formation [1:49:45]; How AI may transform work, identity, and our sense of purpose [1:53:45]; The potential of AI-powered habit change, and the essential—but often lacking—element of motivation [2:02:30]; and More. Connect With Peter on Twitter, Instagram, Facebook and YouTube

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• #359 ‒ How metabolic and immune system dysfunction drive the aging process, the role of NAD, promising interventions, aging clocks, and more | Eric Verdin, M.D.

  View the Show Notes Page for This Episode Become a Member to Receive Exclusive Content Sign Up to Receive Peter’s Weekly Newsletter Eric Verdin is a physician-scientist and the CEO of the Buck Institute for Research on Aging whose career has centered on understanding how epigenetics, metabolism, and the immune system influence the aging process. In this episode, Eric traces his scientific journey from studying viruses and histone deacetylases (HDACs) to leading aging research at the Buck Institute, offering insights into how aging impairs immune and nervous system function—including thymic shrinkage, chronic inflammation, and reduced vaccine response—and how these changes impact lifespan. He explores the metabolic underpinnings of aging, such as oxidative stress and insulin and IGF-1 signaling, and he discusses practical tools like zone 2 cardio, ketogenic diets, and GLP-1 drugs. The conversation also covers declining NAD levels with age, the roles of NAD-consuming enzymes such as sirtuins and CD38, and what current NAD-boosting strategies (like NMN, NR, and IV NAD) can and can’t accomplish. Eric weighs in on promising longevity interventions including rapamycin, growth hormone for thymic regeneration, and anti-inflammatory therapies, while also examining the promise and limitations of current biological age tests and the potential of combining epigenetic, proteomic, and organ-specific metrics with wearables to guide personalized longevity care. We discuss: Eric’s scientific journey from virology to the field of geroscience [2:45]; How dysfunction in the immune system and central nervous system can drive aging throughout the body [5:00]; The role of metabolism and oxidative stress in aging, and why antioxidant strategies have failed to deliver clear benefits [8:45]; Other aspects of metabolism linked to aging: mitochondrial efficiency, fuel utilization, and glucose-modulating drugs [16:30]; How inefficient glucose metabolism drives insulin, IGF-1 signaling, and accelerates aging [21:45]; The metabolic effects of GLP-1 agonists, and the need to move beyond crude metrics like BMI in favor of more precise assessments of metabolic health [27:00]; The case for immune health as a “fifth horseman” [36:00]; How the innate and adaptive immune systems work together to build immune memory [39:45]; Why vaccines lose effectiveness with age: shrinking of the thymus gland and diminished T-cell diversity [44:15]; Exploring growth hormone, thymic regeneration, and the role of exercise in slowing immune aging [48:45]; The challenges of identifying reliable biomarkers for immune function, and the potential of rapamycin analogs to enhance vaccine response in older adults [57:45]; How rapamycin’s effects on the immune system vary dramatically by dosage and frequency [1:03:30]; The limitations of mouse models in aging research and the need for cautious interpretation of rapamycin’s benefits in humans [1:08:15]; NAD, sirtuins, and aging: scientific promise amid commercial hype [1:15:45]; How CD38 drives age-related NAD decline, influences immune function, and may impact longevity [1:23:45]; How NMN and NR supplementation interact with CD38 and NAD metabolism, and potential risks like homocysteine elevation and one-carbon cycle depletion [1:31:00]; Intravenous NAD: limited evidence and serious risks [1:37:00]; Interleukin-11 (IL-11) as a new target in immune aging, the dual role of chronic inflammation in aging, and the need for better biomarkers to guide interventions [1:43:00]; Biological aging clocks: types of clocks, promise, major limitations, and future outlook [1:48:30]; The potential of proteomics-based aging clocks for detecting organ-specific decline and frailty [2:00:45]; and More. Connect With Peter on Twitter, Instagram, Facebook and YouTube

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