Is Peter Attia Overhyping VO2 Max?

Last year Peter Attia was everywhere in the health and longevity space. Between his podcast, his book Outlive, and numerous interviews I watched his views spread across the health space.

In addition to dunking on fasting and pimping protein, his other big idea was that VO2 max is the best predictor of all-cause mortality and healthspan. In interviews, he often seems to downplay nutrition and the role of diet. Instead, he says the research is clear that improving VO2 max is the single best thing one can do for their healthspan. Attia then makes the case for Zone 2 for improving VO2 max.

From his interview with Tim Ferriss:

If we’re going to just talk in magnitude, VO2 max and muscular strength stand in a league of their own.

…That includes having end-stage renal disease, being on the wait list for a kidney while you get dialysis, being a smoker, having high blood pressure, having type two diabetes, being obese. The downside of those things is relatively small compared to the upside of having a high VO2 max and being very strong.

Maybe I am wrong, but I think he has this backward.

The ability to generate a VO2 max (besides genetics which is 40-50%) would benefit tremendously from being healthy first. People with diabetes or high blood pressure probably aren’t training their VO2 max. If they try, they are likely not to be in a state to recover or make sufficient progress. Isn’t the story really that having a low VO2 max is probably a signal of poor health and not that they are unconditioned? In other words, being poorly conditioned is often a result of underlying health issues that prevent the person from doing the conditioning exercises.

A smoker would have impaired VO2 max from their habit alone. Well, except for my former roommate Marlboro Marc. 😁

What about heavy people? People with high BMI tend to have poor VO2 max. Why? I asked Claude.AI to explain

There are a few key reasons why obese individuals tend to have lower VO2 max or maximal oxygen uptake:

Increased body weight. VO2 max is expressed relative to body weight as ml/kg/min. The more someone weighs, the more oxygen they require to move their body. This means for a given absolute VO2 max value, the relative VO2 max is lower in obese individuals.

Higher fat mass. Body fat is essentially “dead weight” that contributes little to oxygen utilization but increases body weight. The greater amount of fat mass acts to reduce VO2 max relative to total body mass.

Reduced muscle mass. Obesity is associated with increased fat mass and reduced muscle mass. Since skeletal muscle is a primary consumer of oxygen during exercise, less muscle mass may result in lower absolute VO2 max.

Impaired cardiorespiratory fitness. Excess fat places greater demands on the cardiovascular and respiratory systems. Obese individuals often have lower cardiovascular fitness levels, resulting in reduced delivery and utilization of oxygen.

Biomechanical disadvantages. Excess body fat can impede efficient movement and exercise. This places greater mechanical stress and oxygen requirements for a given workload.

Inflammation and insulin resistance. Obesity leads to metabolic disruptions that can impair muscle function and limit oxygen use at the cellular level.

Physical inactivity. Obese individuals are less physically active on average, which deconditions the cardiovascular system and fails to improve VO2 max over time.

The majority of people are overweight or obese now. The big lever is not Zone 2 cardio. It is diet. Get lean then get fit. If you try and do them at the same time, you may see great short-term progress. Then your hunger levels will spike and you’ll join the 80% of people who regain their lost weight within four years of dieting. This all assumes you can even exercise safely.

If you are already lean and eating a nutritious diet then Attia might be correct. But then again, you probably are already exercising. Maybe you need to add some additional Zone 2 training, but you are likely already on the right path. Will you see benefits? Against the unhealthy average, absolutely. Compared to the workout plan you were already doing? Maybe a little. I’m skeptical.

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Last Words

Attia’s audience is eating up this information because most are probably already lean and exercise. They are being told that everything they are already doing will give them this amazing healthspan and longevity benefit. Although technically true, I don’t think most of that benefit will come from their training, but from not doing the things that would impair their VO2 max in the first place.

I strongly suspect that the ability to generate a high VO2 max comes first from being extremely healthy and then leveraging that with some conditioning. Not the other way around.

I believe the capacity to generate high VO2 max via genetics and a healthy weight would be more predictive of a better longevity outcome than VO2 max directly. Looking at VO2 max directly is likely just a case of selection and survivorship bias.

I hope I’m wrong and Attia is correct.

15 Comments

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  1. Ken Cooper released his groundbreaking book Aerobics in 1968. If you drove around town in 1970, I don’t think you would see a single jogger/runner. Body building was considered to be for vanity only. Then the pendulum shifted to strength training and “cardio” was dismissed as useless. Now, cardio is back in vogue.

  2. Person A: 50 pounds overweight. Loses 50 pounds via diet. Does not do any exercise aside from walking.

    Person B: 50 pounds overweight. Trains for and completes a full marathon. Also does resistance workouts as part of the training. But does not lose any actual fat during the process. (Maybe we’ll grant that they added a couple pounds of muscle.)

    Which person will show the greatest VO2 MAX increase?

    (I am genuinely asking, I have no idea. VO2 Max is a bit of a mystery to me.)

  3. @M* – I don’t know the answer, but if I had to speculate, I’d say in the short term Person B would show the greatest benefit, but it may not be as sustainable that the person that addressed diet first.

    Year 1 – Person B.
    Liftetime – Person A.

    In financial terms, pay off your credit card debt before you try and grow your stock portfolio.

  4. Stuart Gilbert

    Jan 8, 2024 — 8:47 am

    I have two thoughts on this but both kind of contradict each other.
    Look at the world’s blue zones. Nobody is obsessing about factors to improve longevity like Attia is. He is almost stressing too much about it…which would be a negative surely? Stress isn’t good.
    Look at elderly Asian people exercising outdoors in parks. They are not testing their lactate levels every few minutes to make sure they are in zone 2. They are also not crushing high interval sessions either in order to improve their VO2 max. I’ve yet to hear a centenarian, when interviewed talk about lung bursting interval sessions, high mileage or weight lifting PB’s. They usually talk about the importance of being active, but regulated exercise is rarely mentioned. Those elderly Asian exercising in parks always look like they are having fun and socialising. They usually have a smile on their faces, not a grimace.
    But on the flip side, I saw this video by Rhonda Patrick. She has similar views to Attia ( has even interviewed him recently) but has a different approach of how to get there. It is said by many that zone 2 only works if you have many HOURS per week to devote to it, due to the intensity being so low. This is why the 80/20 approach to endurance training seems to work, usually for those who have the time to devote to putting in the volume of work. Patrick seems to acknowledge that most of us don’t have those hours…and instead recommends a 50 / 50 distribution of high to low intensity endurance work for those of us with limited time.
    https://youtu.be/IxYdkMmtjBs?si=XVAwl1uZplj2wi1t

  5. @Stuart – A few thoughts.

    1- I don’t know how much of the Blue Zone success is really pension fraud.

    2- The Blue Zone outcome is fine. But I think what the longevity movement is hoping to accomplish is to push the boundary a lot more. This means doing what we believe works and then adding to it. Maybe it is Zone 2, maybe not?

    3- My prediction is the future centenarian will look different than the ones of today. They survived a world of disease and scarcity. The next generation of centenarians will need to survive a world of sloth and abundance. We will likely need to update our strategies.

    4- Rhonda seems to parrot everything Attia says now. He changes his views, she changes hers. Protein, fasting, exercise. She has her own twist on Vo2 Max and I would apply the same skepticism to them that I outlined above. Massive selection bias. To be in the top 2 or 3% in VO2 Max is a much bigger story than training alone. Again, I hope I’m wrong.

  6. Stuart Gilbert

    Jan 8, 2024 — 12:04 pm

    MAS,
    I agree with your skepticism about VO2 max. Science still hasn’t determined whether the longevity benefits of a high VO2 max ( or high strength levels for that matter) are due to natural levels and the benefits of good genes, or whether higher levels gained by training are just as beneficial.
    Are some people just destined to live longer regardless? I’m inclined to believe that we can’t increase our life span, but we can do a lot to shorten it.
    As for zone 2…I’m inclined to view it as a fad. Indigo San Millan the main instigator of this “fad” has his detractors in the scientific community apparently. It seems like a backlash to the fad that was HIIT a few years ago. These things go round in cycles…who knows what will come next…

  7. Re: Blue zones
    Anyone looking for a fun read on Blue Zones might enjoy this classic post from Matt Stone.
    Caveat–Matt likes to have fun in his articles.

    https://180degreehealth.com/blue-zones-bullshit/

    Fun facts from the post.
    * Shorter populations live longer.
    *Japanese Americans live longer than the Japanese folks in Japan.

  8. It’s almost as if looking purely at associations doesn’t tell you much. That’s how you could look at a longevity/cholesterol chart and deduce that low cholesterol kills you, whereas there’s almost no limit to how much cholesterol is beneficial.

  9. Craig A Pawlisch

    Jan 11, 2024 — 9:24 pm

    It it important to remember that Attia is a former competitive endurance athlete (marathon swimming, cycling). By his own admission he loved to accumulate huge amounts of training volume. Now that he is not competing at anything athletically, I believe that he has created this centurion decathlon idea partly to justify the continuation of a lifestyle that incorporates an usually high volume of exercise (1 or 2 workouts a day, up to 14 hours per week). He loves living that way, but he falls into an unusual minority of people in that regard.

    That background also means that he lived for a long time in the world of competitive endurance training. A lot of his exercise ideas are driven by what people in that arena do to chase performance. I think he is making the assumption, not fully tested, that what works for endurance performance also works for health and longevity.

    I think he sometimes fails to adequately take into account both of these points when selling an exercise prescription to “ordinary” folks.

    As for VO2max: I have no doubt that there is a strong correlation between VO2max and longevity. But, as you have stated, part of having an exceptional VO2max is a matter of having favorable genetics. Maybe the same genes that favor high VO2max also favor longevity? Whether or not a high volume of training in someone lacking those genes would also give the same longevity boost is somewhat speculative.

    I’ve also seen a few papers that speculate on the role that reverse causation has on these correlations. My impression is that the kind of athlete Attia admires, the guys with super high VO2max, are basically genetic freaks who also do a freakishly high amount of training volume. It probably takes a pretty robust constitution to spend 20 or 30 hours a week doing the kind of training that a super endurance athlete puts in. Maybe these guys are living longer because only super healthy and super robust individuals are able to survive and thrive on that kind of training routine. Perhaps being super healthy and super robust is the main reason for the good outcomes; they might have similar outcomes and lot more free time if they didn’t train as much. But those guys and gals don’t end up on Attia’s radar.

    As for Zone 2: I have no doubt the 80/20 rule, and doing a high volume of Zone 2 is a pretty good way to train for a high level of endurance performance.. Someone doing a high volume of zone 2 will build up a huge reservoir of mitochondria in the muscles they are using for their chosen sport.. But I think that is very activity specific: building up a bunch of mitochondria in your swimming muscles probably doesn’t help all that much if your competitive sport is running or rowing. How relevant those extra mitochondria are for general health and longevity is perhaps not so well established.

    I’ve also seen anecdotal evidence that doing a high volume of zone 2 exercise eventually does produce an unusually large heart (eccentric cardiac hypertrophy) and this leads to unusually high stroke volumes and very low resting heart rates (some of these guys end up with resting heart rates in the 30’s). But I think it takes years of training, with at least 8-10 hours per week of volume, to produce that kind of outcome. Attia, for reasons of practically, suggests his patients start with 45 minutes of cardio 4 times a week. I have doubts that this level of training will produce the kind of outcomes that you see at the extreme end of the athletic endurance spectrum.

  10. Craig P said :

    Perhaps being super healthy and super robust is the main reason for the good outcomes; they might have similar outcomes and lot more free time if they didn’t train as much. But those guys and gals don’t end up on Attia’s radar.

    Jack Lalanne was the great guru of exercise in the 50s and 60s and lived until he was 96.

    But I recall reading that his brother, who lived a regular life and did none of that exercise stuff, lived just as long! Until age 97 in fact.

    Of course, his brother did play rugby and football during his college years in the 1930s.

  11. @Craig – I do sense a strong confirmation and selection bias with Peter Attia.

    I am reminded of this post I did on Bootcamp training back in 2012.
    https://criticalmas.org/2012/01/the-problem-with-boot-camp-training/

    Bootcamp didn’t make my platoon super fit.

    The recruiters only picked young recruits and then the medical screeners removed the unhealthy. But to an outside observer, it looks like Army Boot Camp is a path to amazing fitness.

  12. Stuart Gilbert

    Jan 14, 2024 — 1:20 am

    If Attia is correct then this triathlete, Kristian Blummenfeld, who has a tested VO2 max of 96 should practically live forever…
    https://youtu.be/AQm254ktjPY

  13. I’ve listened to a few interviews about Attia’s new book and every time he talks about VO2 max and strength and ACM I wonder if he’s simply confusing correlation with causation or if I don’t understand his reasoning. You’d think someone that smart/high level would consider that, but I don’t know. None of the interviewers ever ask either. Am I missing something?

    As for Zone 2 – certainly could be over hyped by Attia. That said, I suspect the benefits of simply more blood flow, sweating, getting hot and lower/moderate intensity muscle use are probably understated. I doubt such things are studied well. I’ve heard studies on walking that are very interesting. I’ve noticed magic when I get my heart rate up to a moderate clip for an extended period of time. So I do think obese people could probably benefit greatly from it to the point of likely living longer. Diet could be the bigger lever. I’m not sure and I’m not sure if Attia would disagree either.

  14. @HS – We agree. It is too bad that Art De Vany is no longer active in fitness discussions (he is 86). He knows fitness and he is a trained economist. An economist would be able to ask better questions and find bias in arguments.

  15. Stuart Gilbert

    Jan 17, 2024 — 9:57 am

    I remember this study coming out in 2018. It showed that people who played tennis and badminton had far greater longevity outcomes than people who ran, swam, cycled or did health club activities.
    Now tennis and badminton, as played by the non elite, aren’t necessarily HIIT in nature, but they probably aren’t zone 2 steady state either.
    Now the study was an observational one. The authors only speculated why tennis and badminton were better. They theorised that it was due to the social aspects of the sports. It could also be due to the fact that those who can afford to play tennis have a better lifestyle and healthcare. Or it could be something advantageous about the stop start nature of the sports, an easier interval training session if you will. Whatever it is, playing tennis sure seems more appealing than Attia’s approach of spending long, lonely hours on a bike trainer. There is a “fun” aspect that Attia’s OCD approach certainly lacks. I can’t see too many takers for those “extra” years if it meant “hours” a week on a bike or treadmill. But to get people down at the Pickleball courts, with the bonus that they might very well live longer, is an easier sell.
    https://www.mayoclinicproceedings.org/article/S0025-6196(18)30538-X/fulltext

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