I've heard you talk before about some of the prime movers for longevity and all-risk mortality. And I'd love for you to review a little bit of that for us. I think we all know that we shouldn't smoke because it's very likely that we'll die earlier if we smoke nicotine.

I'm neither a marijuana nor a nicotine smoker, so I feel on stable ground there. But anytime we see smoking nowadays, people really want to distinguish between cannabis and nicotine. So I am curious about any differences there in terms of impact on longevity. But in that context, what are the things that anyone and everyone can do, should do to live longer basically?

How long you got? Well, you tell me. You tell me. I'd like to live to be, I'd like my final decade to be between 90 and 100. Oh, no. I meant how long do you- No, no. I'm just kidding. I'm just kidding. And will we spend from now until you're 90 talking about this?

Well, there's a risk of that. So let's start with a couple of the things that you've already highlighted. So smoking, how much does smoking increase your risk of all-cause mortality? And the reason we like to talk about what's called ACM or all-cause mortality is it's really agnostic to how you die.

And that doesn't always make sense. I mean, if you're talking about a very specific intervention, like a anti-cancer therapeutic, you really care about cancer-specific mortality or heart-specific mortality. But when we talk about these sort of broad things, we like to talk about ACM. So using smoking, smoking is approximately a 40% increase in the risk of ACM.

What does that translate to? That means I'm shortening my life by 40%? No. It means at any point in time, there's a 40% greater risk that you're going to die relative to a non-smoker and a never-smoker. So it's important to distinguish. It doesn't mean your lifespan is going to be 40% less.

It means at any point in time standing there, your risk of death is 40% higher. And by the way, that'll catch up with you, right? At some point, that catches up. High blood pressure. It's about a 20% to 25% increase in all-cause mortality. You take something really extreme, like end-stage kidney disease.

So these are patients that are on dialysis waiting for an organ. And again, there's a confounder there, because what's the underlying condition that leads you to that? It's profound hypertension, significant type 2 diabetes that's been uncontrolled. That's enormous. That's about a 175% increase in ACM. So the hazard ratio is like 2.75.

Type 2 diabetes is probably about a 1.25 as well, so a 25% increase. So now the question is, how do you improve? So what are the things that improve those? So now here we do this by comparing low to high achievers and other metrics. So if you look at low muscle mass versus high muscle mass, what is the improvement?

And it's pretty significant. It's about 3x. So if you compare low muscle mass people to high muscle mass people as they age, the low muscle mass people have about a 3x hazard ratio, or a 200% increase in all-cause mortality. Now if you look at the data more carefully, you realize that it's probably less the muscle mass fully doing that, and it's more the high association with strength.

And when you start to tease out strength, you can realize that strength could be probably 3.5x as a hazard ratio, meaning about 250% greater risk if you have low strength to high strength. And high strength is the ability to move loads at 80% to 90% at one repetition. And it's all defined by given studies.

So the most common things that are used are actually-- they're used for the purposes of experiments that make it easy to do, and I don't even think they're the best metrics. So they're usually using grip strength, leg extensions, and wall sits, squats, things like that. So how long can you sit in a squatted position at 90 degrees without support would be a great demonstration of quad strength, a leg extension.

How much weight can you hold for how long relative to body weight, things like that. We have a whole strength program that we do with our patients. We have something called the SMA, so it's the Strength Metrics Assessment. And we put them through 11 tests that are really difficult, like a dead hang is one of them, like how long can you dead hang your body weight, stuff like that.

So we're trying to be more granular in that insight, but tie it back to these principles. If you look at cardiorespiratory fitness, it's even more profound. So if you look at people who are in the bottom 25% for their age and sex in terms of VO2 max, and you compare them to the people that are just at the 50th to 75th percentile, you're talking about a 2x difference roughly in the risk of ACM.

If you compare the bottom 25% to the top 2.5%, so you're talking about bottom quarter to the elite for a given age, you're talking about 5x, 400% difference in all cause mortality. That's probably the single strongest association I've seen for any modifiable behavior. Incredible. So when you say elite, these are people that are running marathons at a pretty rapid clip?

Not necessarily. It's just like what the VO2 max is for that, like my VO2 max would be in the elite for my age group. My VO2 max, but again, I'm training very deliberately to make sure that it's in that. So I wouldn't consider myself elite at anything anymore, but I still maintain a VO2 max that is elite for my age.

I consider you an elite physician and podcast and guy all around, but true. But in terms of, okay, so for the point is like, you don't have to be a world-class athlete to be elite here. Yeah. Got it. So maybe we can talk a little bit about the specifics around the training to get into that, um, you know, top two tiers there because it seems that those are enormous positive effects of cardiovascular exercise, uh, far greater than the sorts of numbers that I see around, let's just say supplement a or supplement b.

And that's, you know, like this is my whole pet peeve in life, right? It's like, I just can't get enough of the machinating and arguing about this supplement versus that supplement. And I feel like you shouldn't be having those arguments until you have your exercise house in order. Um, you know, you shouldn't be arguing about your, this nuance of your carnivore diet versus this nuance of your paleo diet versus this nuance of your vegan diet.

Like until you can deadlift your body weight for 10 reps, like then, then you can come and talk about those things or something like, let's just start with some metrics like until your VO2 max is at least to the 75th percentile and you're able to dead hang for at least a minute and you're able to wall sit for at least two, like we could rattle off a bunch of relatively low hanging fruit.

I wish there was a rule that said like you couldn't talk about anything else health related. We can make that rule. No one will listen to it. I don't know about that. We can make whatever rules we want. We can call it a Tia's rule. One thing I've done before in this podcast on social media is just borrowing from the tradition in science, which is it's inappropriate to name something after yourself unless you were a scientist before 1950.

Um, but it's totally appropriate to name things after other people. So I'm going to call it a Tia's rule until you can do the following things. Um, don't talk about. Please refrain from talking about supplements and nutrition. There it is. Hereafter thought of, referred to and referenced as a Tia's rule.

I coined the phrase, not him, so there's no ego involved, but it is now a Tia's rule. Watch out. Hashtag a Tia's rule. Oh God. Um, Wikipedia entry, a Tia's rule in all seriousness, and I am serious about that. Um, dead hang for about a minute seems like a really good goal for a lot of people, at least.

That's our, that's our goal. I think we have a minute and a half is the goal for a 40 year old woman. Two minutes is the goal for 40 year old man. So we adjust them up and down based on, uh, age and gender. Great. And then, uh, the wall sit.

What's, what are some numbers? We don't use a wall sit. We do as, as just a straight squat, air squat at 90 degrees. Um, and I believe two minutes is the standard for both men and women at 40. Great. And then, uh, because for some people thinking in terms of, you know, two max is a little more complicated.

They might not have access to the equipment or the, to measure it, et cetera. Um, what can we talk about, think about in terms of cardiovascular? So run a mile at, uh, seven minutes or less, eight minutes. That's a good question. So there are VO two, there are really good VO two max estimators online and you can plug in your activity du jour.

So be at a bike run or rowing machine and it can give you a sense of, of that. And I, I don't remember. I used to know all of those, but now that I just actually do the testing, I don't recall them. But it's exactly that line of thinking, like, can you run a mile in this time?

If you can, your VO two max is approximately this. Great. And, and, and I think somewhere in my podcast realm, I've got all those charts, charts posted of like, this is by age, by sex. This is what the VO two max is in each of those buckets. Terrific. We'll provide links to those.

We'll have our people find those links. And then, um, you mentioned deadlifting body weight 10 times. I just made that one up. We don't, that's not one that we include, but, but something, something like that. Um, we use, we use farmer carries. So we'll say for a male, you should be able to farmer carry your body weight for, uh, I think we have two minutes.

So that's half your body weight in each hand. Um, you should be able to walk with that for, for two minutes. Um, for women, I think we're doing 75% of body weight or something like that. Yeah. Great. I love it. Um, as indirect measures of how healthy and how long we're going to live.

It's basically grip strength. It's mobility. I mean, again, walking with that much weight for, for some people initially is really hard. Um, you know, we use different things like vertical jump, ground contact time. If you're jumping off a box, things like that. So it's, it's really trying to capture and it's, it's an evolution, right?

Like I think the, the test is going to get only more and more involved as we, as we, as we get involved. Cause it took us about a year. Beth Lewis did the majority of the work to develop this. Um, Beth runs our strength and stability program in the practice.

And you know, basically I just tasked her with like, Hey, go out to the literature and come up with all of the best movements that we think are proxies for what you need to be like the most kick-ass, you know, what we call centenarian decathlete, which is the person living in their marginal decade at the best.