The Peter Attia Drive

• #373 – Thyroid function and hypothyroidism: why current diagnosis and treatment fall short for many, and how new approaches are transforming care | Antonio Bianco, M.D., Ph.D.

  View the Show Notes Page for This Episode Become a Member to Receive Exclusive Content Sign Up to Receive Peter's Weekly Newsletter Antonio Bianco is a world-renowned physician-scientist and expert in thyroid physiology and metabolism. In this episode, Antonio explores the complex biology of thyroid hormone production, conversion, and regulation—highlighting how deiodinase enzymes modulate hormone activity at the tissue level and why that matters for interpreting lab results. He discusses the shortcomings of relying solely on TSH as a marker of thyroid function, the ongoing debate around combination therapy with T3 and T4 versus standard T4 treatment, and how genetics, tissue sensitivity, and individual variability influence thyroid hormone metabolism. The conversation also examines how hypothyroidism affects energy, mood, cognition, and longevity; why some patients remain symptomatic despite "normal" labs; and how future research could reshape treatment paradigms. We discuss: How the thyroid produces, stores, and activates hormones like T4 and T3 to finely regulate thyroid activity [2:45]; How fasting alters thyroid hormones to conserve energy [12:45]; Action of the deiodinases: how D1, D2, and D3 enzymes control the activation and inactivation of thyroid hormones [19:15]; The normal function of thyroid hormone and the roles of the hypothalamus, pituitary gland, and deiodinases in maintaining hormonal balance [23:30]; Why understanding thyroid physiology is essential for proper diagnosis and treatment of hypothyroidism [33:45]; Testing for thyroid hormones: understanding free vs. total levels, the limitations of current T3 assays, best practices, and more [36:00]; Genetic and sex-based variability in thyroid hormone regulation and their limited clinical significance [43:45]; Hyperthyroidism: causes, symptoms, diagnosis, and treatment options [46:00]; Hypothyroidism: diagnosis and autoimmune causes of hypothyroidism [56:30]; More on hypothyroidism: diagnostic biomarkers, antibody patterns, and non-autoimmune presentations [1:05:00]; Thyroid hormone replacement therapy [1:15:15]; More on thyroid replacement strategies: exploring the evidence gaps, mortality signals, effects on lipids, and more [1:28:00]; Hypothyroidism basics: causes, antibody implications (including pregnancy), and how to make the diagnosis before choosing therapy [1:35:15]; Thyroid medication: compounded controlled-release T3, brand name versus generic, and what Antonio prescribes to newly diagnosed hypothyroid patients [1:42:45]; Redefining treatment success: why normalizing TSH isn't always enough for patients with hypothyroidism [1:54:45]; Case studies: analysis of two unusual cases of thyroid disease [1:57:00]; Dangers of supplementing with high levels of iodine, and female-specific risk of thyroid disease [2:05:45]; Case study of a patient who presents with elevated TSH but no symptoms [2:09:30]; How future research could reshape treatment, and Antonio's new book called "Rethinking Hypothyroidism" [2:13:15]; and More. Connect With Peter on Twitter, Instagram, Facebook and YouTube

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• #372 - AMA #77: Dietary fiber and health outcomes: real benefits, overhyped claims, and practical applications

  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 breaks down the science of dietary fiber, moving beyond the blanket advice to "eat more fiber" to uncover what it actually does in the body and where its benefits are truly supported by evidence. He explains how different types of fiber—soluble, insoluble, viscous, and fermentable—affect digestion, satiety, weight management, and glycemic control, and compares their impact to other, more potent metabolic tools. Peter also examines how certain fibers influence lipid metabolism and cardiovascular risk, evaluates the strength of evidence for fiber's role in colorectal cancer prevention, and highlights why some individuals may not tolerate specific fibers well. The discussion concludes with practical guidance on moving past generic fiber targets toward a more strategic and personalized approach that maximizes the true benefits of fiber. 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 #77 show notes page. If you are not a subscriber, you can learn more about the subscriber benefits here. We discuss: Why it's time to re-examine the evidence behind dietary fiber recommendations [2:00]; Why it's hard to isolate fiber's true effects on health: the limits of nutritional epidemiology [5:45]; Defining dietary fiber: what it is, how it's digested, and why different types have different effects [8:15]; Understanding fiber properties: how solubility, viscosity, and fermentability shape its effects in the body [11:15]; Resistant starches explained: types, food sources, and how cooking and cooling influence their benefits [16:30]; A framework for evaluating each of the major health claims linked to fiber [19:15]; How fiber can support weight loss: mechanisms, realistic expectations, and its complementary role to broader dietary strategies [20:30]; How fiber modestly improves glycemic control by reducing glucose spikes and insulin demand [26:15]; How fiber modestly lowers LDL cholesterol and supports cardiovascular health [34:30]; How fiber compares to other available tools and strategies for managing lipids, blood sugar, and weight [42:00]; Fiber's role in colon cancer prevention: mechanisms, evidence, and limitations [45:30]; Is fiber necessary for colon cancer prevention in otherwise healthy individuals? [53:30]; Why some people have adverse reactions to certain types of fiber, and how to manage them [56:00]; A general strategy for dietary fiber: combine multiple fiber types through whole foods and supplements [58:45]; Why total fiber intake is more important than the ratio of soluble-to-insoluble fiber [1:02:45]; The optimal timing and context for consuming fiber to maximize blood sugar control and metabolic benefits [1:05:00]; How food processing affects the functional properties of fiber, the differences between supplement forms and natural sources, and why whole foods generally remain the best option [1:06:45]; Fiber's potential to interfere with medication absorption [1:09:30]; How to safely increase fiber intake: ramp up gradually and stay hydrated [1:12:00]; Final takeaway on fiber: modest benefits, strong rationale, low downside [1:13:00]; Peter's carve-out: lessons and inspiration from the Acquired podcast [1:14:30]; and More. Connect With Peter on Twitter, Instagram, Facebook and YouTube

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• #371 – Women's sexual health: desire, arousal, and orgasms, navigating perimenopause, and enhancing satisfaction | Sally Greenwald, M.D., M.P.H.

  View the Show Notes Page for This Episode Become a Member to Receive Exclusive Content Sign Up to Receive Peter's Weekly Newsletter Sally Greenwald is an OB-GYN who specializes in women's sexual health from a hormonal and physiologic perspective, with expertise spanning desire, arousal, pelvic floor function, contraception, and menopause care. In this episode, she explains why sexual health is a vital component of overall well-being, exploring topics such as the drivers of desire, the anatomy of sexual function, myths and realities around orgasm, and the role of hormones in perimenopause and menopause. She also covers vaginal and pelvic health, pain with sex, evidence-based therapies for low desire and arousal, how contraception and medications can affect sexual function, and practical strategies for enhancing sexual satisfaction and maintaining intimacy across life stages. This episode offers a comprehensive, evidence-based discussion with immediate real-world relevance for women as well as for men who want to better understand their partners. We discuss: How sexual health influences physical health, emotional well-being, and relationships [3:15]; Understanding the physiology of the female orgasm, sexual comfort and satisfaction, and the disparity between men and women [12:45]; Foreplay, the science of desire, and methods to help women cultivate arousal and connection [19:00]; The physiology and sources of female lubrication, the role of clitoral nerve anatomy in pleasure, and the use of lubricants and vibrators to enhance comfort and sexual health [23:45]; Understanding female anatomy and what is needed for orgasm [31:15]; Understanding sexual desire, how to cultivate it, the role of hormones, and testosterone therapy in women [41:15]; Personalizing perimenopause care: how desire for ovulation guides the choice between contraception and menopausal hormone therapy [49:30]; Considerations for choosing contraceptives and hormonal therapies during perimenopause [59:45]; Factors negatively affecting desire, and why female libido persists with age and fluctuates across the menstrual cycle [1:11:00]; How sexual trauma and physical pain can affect sexual health, and evidence-based strategies for recovery [1:15:15]; Vaginal care routine: lubricants, moisturizers, topical hormones, and other approaches for vaginal health [1:19:15]; Tips for sexually satisfying your female partner [1:25:45]; The pharmacology of arousal: various treatments for low sexual desire in women [1:30:30]; Sex during and after pregnancy: impact on arousal, safety of sex, and how to manage postpartum recovery and pain [1:37:45]; How Sally would redesign sex education [1:42:15]; Sally's optimism about a new era in women's sexual health [1:49:00]; and More. Connect With Peter on Twitter, Instagram, Facebook and YouTube

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• Longevity 101: a foundational guide to Peter's frameworks for longevity, and understanding CVD, cancer, neurodegenerative disease, nutrition, exercise, sleep, and more (re-broadcast)

  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 special episode, Peter provides a comprehensive introduction to longevity, perfect for newcomers or those looking to refresh their knowledge. He lays out the foundational concepts of lifespan, healthspan, and the marginal decade. Additionally, Peter discusses the four main causes of death and their prevention, as well as detailing the five key strategies in his longevity toolkit to improve lifespan and healthspan. Detailed show notes provide links for deeper exploration of these topics, making it an ideal starting point for anyone interested in understanding and improving their longevity. We discuss: Key points about starting exercise as an older adult [2:45]; Overview of episode topics and structure [1:45]; How Peter defines longevity [3:45]; Why healthspan is a crucial component of longevity [11:15]; The evolution of medicine from medicine 1.0 to 2.0, and the emergence of medicine 3.0 [15:30]; Overview of atherosclerotic diseases: the 3 pathways of ASCVD, preventative measures, and the impact of metabolic health [26:00]; Cancer: genetic and environmental factors, treatment options, and the importance of early and aggressive screening [33:15]; Neurodegenerative diseases: causes, prevention, and the role of genetics and metabolic health [39:30]; The spectrum of metabolic diseases [43:15]; Why it's never too late to start thinking about longevity [44:15]; The 5 components of the longevity toolkit [46:30]; Peter's framework for exercise—The Centenarian Decathlon [47:45]; Peter's nutritional framework: energy balance, protein intake, and more [58:45]; Sleep: the vital role of sleep in longevity, and how to improve sleep habits [1:08:30]; Drugs and supplements: Peter's framework for thinking about drugs and supplements as tools for enhancing longevity [1:13:30]; Why emotional health is a key component of longevity [1:17:00]; Advice for newcomers on where to start on their longevity journey [1:19:30]; and More. Connect With Peter on Twitter, Instagram, Facebook and YouTube

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• #370 - AMA #76: Peter evaluates longevity drugs, aspirin for CVD, and strategies to improve muscle mass — proven, promising, fuzzy, noise, or nonsense?

  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 revisits the "proven, promising, fuzzy, noise, nonsense" scale and applies it to a variety of popular topics. He begins with a refresher on what each category represents before classifying a range of interventions based on the strength of their supporting evidence. The conversation spans three main areas: drugs for geroprotection (including GLP-1 receptor agonists, SGLT2 inhibitors, methylene blue, and telomere-lengthening supplements), the use of low-dose aspirin for cardiovascular disease prevention, and strategies to improve muscle mass through optimal protein intake and follistatin gene therapy. This episode provides a clear, evidence-based overview for listeners seeking to understand where these popular health and longevity interventions stand on the spectrum of scientific credibility. 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 #76 show notes page. If you are not a subscriber, you can learn more about the subscriber benefits here. We discuss: A scale for evaluating scientific claims: proven, promising, fuzzy, noise, or nonsense [1:30]; Strong convictions, loosely held: the mindset that separates great scientists from the rest [7:30]; GLP-1 receptor agonists: are there benefits beyond improving metabolic health and promoting weight loss? [12:45]; GLP-1 drugs and the brain: exploring the potential cognitive benefits [18:45]; GLP-1 drugs and lifespan: examining the evidence for potential geroprotective effects [23:00]; Rapamycin and geroprotection: why it remains in the "promising" category [25:45]; SGLT2 inhibitors and their potential geroprotective effect [27:30]; Methylene blue: examining the evidence of an anti-aging effect [34:45]; Methylene blue's potential neuroprotective effects: limited and inconsistent evidence in humans, and the challenges of dosing and safety [41:15]; Telomeres: what they are, how they relate to aging, and why telomere-lengthening supplements lack credible scientific evidence [43:45]; Does the idea of targeting telomere length to extend lifespan have scientific merit? [50:15]; Low-dose aspirin for cardiovascular disease prevention: weighing its clot-prevention benefits against bleeding risks across different populations [55:00]; Rethinking the protein RDA: why most people need twice the recommended amount for muscle health [1:00:45]; Debunking the protein–cancer myth: why higher protein intake doesn't promote tumor growth [1:06:15]; The biology of follistatin and myostatin, and why follistatin gene therapy has become an emerging topic of interest for muscle growth [1:13:15]; Follistatin gene therapy for muscle growth: state of the evidence in animals and humans, and the technical challenges and regulatory barriers [1:17:00]; Why injectable follistatin is theoretically possible but impractical for real-world use [1:23:15]; and More. Connect With Peter on Twitter, Instagram, Facebook and YouTube

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