The 6 rules you need for a long, healthy life: How to cut your risk of dementia, heart disease, and cancer with Dr. Ezekiel Emanuel

What really helps you live a long, healthy life? Can healthy ageing be as simple as a few everyday habits?

In this episode, Dr. Ezekiel Emanuel, world-leading oncologist, bioethicist and World Health Organization adviser, shares six rules from his book Eat Your Ice Cream that may help lower your risk of dementia, heart disease, cancer and early death. 

Ezekiel explores the science of healthy ageing, longevity and disease prevention, and explains why many wellness trends distract us from what matters most.

If you want to live a longer, healthier life, are you focusing on the habits that matter most? 

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Jonathan: Zeke, is loneliness worse for your health than smoking tobacco?

Ezekiel: Yes.

Jonathan: Is being president of the United States more dangerous than climbing Everest?

Ezekiel: It's definitely a more schmucky move.

Jonathan: Do books written by wellness influencers usually give good advice?

Ezekiel: It's mixed.

Jonathan: Is the wellness industry overall doing more harm than good?

Ezekiel: Hard to know.

Jonathan: Do you have six rules to help us live longer, healthier lives?

Ezekiel: Absolutely.

Jonathan: And finally, what's the biggest thing that the wellness industry gets wrong?

Ezekiel: Social relations. They're the most important thing you can do for your wellness, longevity, and happiness.

Jonathan: Most of the people listening to this podcast, myself included, are sort of overwhelmed by a tidal wave of wellness information we get on podcasts, on social media, from our friends, you know, from the traditional media. And we're bombarded with ads therefore for supplements and red light therapy and coffee enemas and superfoods and, you know, the list goes on and on, and I feel like every week somebody tells me about this brand-new thing that you can do. So I think it's no surprise that we all feel very confused about what we should actually do. So Zeke, I'm delighted to have you with us today to hopefully help make sense of it all, and your new book outlines six simple rules for a long, healthy life. And so I was curious what inspired you to write this book.

Ezekiel: Anger.

Jonathan: Anger?

Ezekiel: So in December 2023, I had finished teaching in the United States, but finals and grades hadn't, weren't due in, and Peter Attia's Outlive arrived at my house. Now, I certainly didn't order it 'cause I didn't even know it existed. I thought my brother sent it to me, but he denies it. He says he's never even seen the book. So I just sat down and read it. It's 415 or so pages, and it just made me more and more furious as I got to the end. And I literally finished the book in a short flash and sat down in the next three weeks and wrote 35,000 words, and that was the first draft of this book. And what really made me mad is his obsession about exercise, a little bit about food, a little bit about sleep, but he left out the most important thing about wellness, which we just talked about, which is social relationships. He has a two-page afterword. And in the afterward he says, "Well, you can be in great shape, you can be able to, you know, bench press 250 pounds, but if your relationship with your wife is terrible, if you don't have good friends, you know, what's it for?" And yet the book doesn't deal with the fact that social relations are so important to you, not just psychologically, physically to your body. And so that was the genesis. And I had previously worked out in my head that there are these six rules, they're pretty simple, but that was the catalytic moment, if you will, that drove me.

Jonathan: And Zeke, are you regularly, like, driven to such levels of fury by a book that arrives in front of you that you write your own book as a riposte?

Ezekiel: A riposte. No. This is the first time that's ever happened, and the first... I won't say the first time things flowed out magically, and you, like, look back and you say, "Well, how did I do that? Well, how did I put it all together?" 'Cause it just seems... I mean, some writers say, report, you know, "I was just the conduit for some higher force." It does, it has that kind of feel to me. Once I wrote an article, which I'm sort of infamous for, "I Want to Die at 75," and that also in three days I just finished the article and with minor touch-ups, that's what got published. So there are some times when it does work, it just flows out. But this was quite, I mean, 35,000 words. It was quite unusual.

Jonathan: So you were really upset by this book. You felt that this book was-

Ezekiel: It was a total disservice to humanity, and it was getting a lot of attention. And I was like, "This is diverting people from the way they need to really think about wellness." I mean, I'd say the other thing that the wellness industrial complex gets wrong is this sort of... I mean, it gets lots of things wrong. One is to be obsessed about wellness. You should not be obsessed about wellness. You should be obsessed about living a meaningful life. That's really what's important, and wellness is only a means to an end. The second thing is, a lot of it's about self-denial. You know, things you should go on and you should, you know, work out until it really hurts. Wrong. If you're gonna do wellness, you're gonna do it for decades, and you will not sustain self-denial for decades, and that's why people give up on their New Year's resolutions, give up on their diets, because it's mostly built around self-denial. So this book is much more serious about, you know, first of all, biology for humans is about homeostasis, the balance between one extreme and another. And this is something, you know, Aristotle understood. You know, the happy medium, the golden middle. And, you know, it really is true in the body. You know, if your immune system is very active, right, you have autoimmunity and you attack yourself. If it's too lax, you know, you will get infections and so you have to get a middle. And the body is exquisitely tuned to moderation and not to go to extremes. And yet the wellness industrial complex, if something is good, right, eating something is good, you should go and max it. That's their phrase, max it out. And no, maxing is not biological.

Jonathan: I love it. I also love this phrase, the wellness industrial complex, which is a new one on me. Why has that complex, as you put it, exploded recently? Because this is definitely different from what I grew up with.

Ezekiel: This isnt the first time wellness has sort of exploded and become an obsession of the population and society. Between roughly 1870 and 1914, we had the same interest. Lots have turned to vegetarianism, exercise, worry about fresh air, worry about the foods you eat. There was actually an anti-vax movement then. The vaccine was smallpox. And if you look at the two periods of time, they have a lot of similarities. Industrial revolution in the late 19th century, AI and the revolution around knowledge today. Lots of small wars then, same thing today. You also have a lot of income inequality at that time, and then you also have lots of uncertainty for people. And I think what that shows you is that wellness is a response to a topsy-turvy world, a lot of uncertainty about what the future's bringing, people feeling like their life's out of control. And so wellness is a response. This is something I can control, what I eat, the vaccines I get, the exercise, and I think that's what we have today. This is a lot about self-control transmuted into wellness as the outlet. So that's the big social explanation. I think the personal explanation is people want to live healthy. They don't wanna have these chronic diseases, and they're trying to figure out, well, what can I do, besides taking a lot of medications, that'll make me healthier? Here's an interesting historical fact. Trying to look at the history of the wellness industry, I came across an article in the St. Louis Post-Dispatch, 1909, and the headline reads, "Researcher Says Science Will Be Able to Allow Us to Live to 150 Years." Could've been written yesterday by a wellness influencer. The same motivation, you know. But, you know, the data are that that's very unlikely, and here's why. We have more people living to 90, more people who are centenarians, than ever before. But it turns out the top period, how long people can live, roughly 120 years is the max, hasn't moved, and very unlikely to move. And so I think we have to recognize that it is true we can postpone decline. We can live healthier up until our 90s. Most people at their 90s, even if they've lived an active life, are, you know, things are beginning to slow down substantially.

Jonathan: I'd just like to circle back to this idea that there are things that the wellness industry is getting wrong, and I can see this one book, which I have read, triggered a lot of fury. But if you're gonna step back more broadly across this whole industry, what are the main things for you that they're getting wrong? Because I think a lot of people listening will say, "But, like, they tell you to do more exercise and think more about what you're doing. Surely this is basically all great."

Ezekiel: No. First of all, it isn't all great. Let me just give you one example, the exercise example. So if you follow Peter Attia, 10 hours a week, that's what he recommends, and he's got it broken down by various things. It turns out that there's a plateau in terms of exercise as to how much you will improve your longevity if you exercise more, and that plateau is around 150 minutes of vigorous exercise every week and about 300 minutes, five hours of moderate exercise every week. And beyond that, there's no real bump in terms of longevity. But what is there if you keep exercising?

Jonathan: Well...

Ezekiel: The most important thing is what the economists call opportunity cost. What could you be doing in those five hours that you're not doing because you're pumping iron in a gym or you're out running or rowing? Now, I'm not saying those aren't bad things and you can't be rejuvenated by them, but I do think that there's big opportunity cost by spending too much time obsessing about these activities that they recommend. And that, again, goes to this issue that they make wellness the center of life as opposed to a means to the ends, which is a fulfilling life. Seven and a half hours a week while you're awake is a substantial portion of your wakefulness hours. So, you know, you got to figure what should I be doing in that time? Maybe you should be reading a book cover to cover. That's just one thing. You could spend that time with, you know, close friends. There are lots and lots of good things you can do that are good for your community and also good for you.

Jonathan: Is that the only thing that -- Is it just exercise duration that the wellness industry is getting wrong?

Ezekiel: No. I mean, they're selling you lots of goods, you know, this supplement, that supplement. First of all, for many of them it's just a waste of money. Some of them are probably dangerous for you. You know, this whole new wave of peptides. Take these peptides and, you know, stack them. Don't take one. Why one is okay, but let's max it. Let's go five at one time. Just idiotic and probably dangerous.

Jonathan: Not everyone will understand what peptides are. Obviously, there's been an explosion of this online, particularly in the States because the regulations are much lower. In a lot of other countries it's harder to get them. And so I just want to make sure that everyone understands. Could you just explain what's going on, and then can you talk about whether they're safe?

Ezekiel: Peptides are basically short proteins. So the body is full of proteins. That's how we live. The DNA codes proteins, and things like insulin are proteins or these new weight loss drugs, GLP-1s are proteins and... peptide. And peptide is just a short protein. And they have a lot of important effects in the body. And we need peptides. We need peptides to signal to cells. We need peptides obviously like insulin to stimulate cells to take up glucose. But these peptides, mainly produced in China, are not well-studied. We don't know their effects in the body. We don't know they're positive. And, you know, like everything, peptides will also have negative effects. Too much of them will be bad, and we don't really understand some of the combinations of these peptides. That's not to say all these peptides, well-produced, very carefully monitored, aren't gonna be good. It is to say that going to a storefront and getting an infusion of peptides for $500 or something is crazy, and probably could very well be dangerous.

Jonathan: So that's-- I think a lot of people think about it a bit like, "Well, I'm just getting some vitamins. What can go wrong?"

Ezekiel: Lots of things can go wrong. You can get a toxic reaction. They might be contaminated in their production. What they say they are, they might not be at all.

Jonathan: And if they are what they claim to be, does that mean they'll be good for you?

Ezekiel: No, because we haven't studied them. People who take these weight loss drugs, the GLP-1s, right? They have side effects, and some of those side effects can be bad. That's why we research them for safety and effectiveness and have rules on who should get them, what the trade-offs are, and how much you should administer.

Jonathan: So this is like just injecting a completely unregulated...

Ezekiel: Yeah.

Jonathan: ...drug in the same way. Certainly in...

Ezekiel: The United States.

Jonathan: ...that is...

Ezekiel: Stupid.

Jonathan: ...does sound quite stupid. I'd love now to sort of get into, you know, the topics that are in your book, and I'd like to start first with sort of what you say we should stop doing before going onto these six simple rules. But I'm very conscious that at ZOE, we don't really like to say you should restrict yourself. We generally feel that this is not sustainable and not a good balance. But I know that there are some things that, you know, are, in your view, things we should worry about, and I'd like to just talk about them for a minute. And can we start with alcohol? Do I need to give it up?

Ezekiel: So alcohol is very controversial. You know, just a few years ago, it was you should have red wine, and red wine's got this magical French element that allows you to drink wine, enjoy it, and live a long time. And now you've got studies from the WHO and in Britain, zero alcohol is the right level. So we should be very clear. We do know that there are downsides to alcohol. We've known this for a long time. It's associated with a dramatic increase of risk of at least seven cancers, liver disease, cirrhosis, and its evolution. We know that it destroys brain cells and so enhances cognitive impairment. But we also know that humans have been drinking it forever. But it's not just humans. You know, birds go to fermented fruits. Chimpanzees and other primates go to fermented fruits, and, you know, nature seems to like the buzz. The other thing is we have to recognize two-thirds of the population in countries actually are drinkers. One-third are teetotalers. You're not going from two-thirds to zero, so we need to be realistic about it. And there are studies about how much is the right amount, and it varies. A recent report out in the United States, probably one drink a day, seven drinks a week. Beyond that, a really dramatic increase so that by eight drinks or nine drinks a week, you get a pretty substantial increase in the risk of mortality. There's also some studies that suggest it's less. It's three or four, which is what I recommend in the book, three or four drinks a week. And I think that's the kind of right level. But the other point I would make is alcohol is a lubricant for social interaction. It allows people to talk, and that's a balance. All right, it's got this increased risk of harms, but it also increases the chance that you're gonna have conversations with people, and you're actually gonna talk, and that's the kind of balance. I happen to be a teetotaler. My wife happens to enjoy alcohol, enjoy cocktails, and I think getting the right balance is very important. Three or four drinks, no binging, don't drink alone, use it in social interactions, and don't use it to drown out your sorrows to avoid dealing with them. Look, when I have a dinner party at home, do I serve alcohol? The answer is yes.

Jonathan: A thing I'd like to talk about next is a topic that we end up talking about on this podcast a lot, which is ultra-processed foods.

Ezekiel: A huge problem. And if you had to say, "All right. Let's look at the last 60, 70 years, what's been the chief problem?" I would say ultra-processed foods because they're bad cognitively. We've got some recent very good studies from Brazil and now one from the United States that they actually accelerate cognitive decline. We also know that they are addictive in the way they're formulated, and they are energy dense, and so they're a major reason we have the obesity epidemic and lots of things follow from the obesity epidemic: increased diabetes, increased renal disease, increased hypertension, increased cardiac disease that is really... that is a major force driving our healthcare expenditures in every country up. Ultra-processed foods are a serious problem. Now, the United States, we are the world's leader in consumption of ultra-processed foods, so adults, about 60% of calories are ultra-processed foods. Britain, a good close second. You know, you're in 50-plus percent of calories ultra-processed foods. That is an area you definitely have to reduce substantially. The contrast class is, you know, Italy. Italians are about 20% of calories ultra-processed foods, and that's where we have to move to and start with two things in my view. First, stop with the sodas. Zero nutritional value. Just stop. And diet sodas, no better. They're just as bad for you. And the second thing we have to do is decrease the packaged snacks. Packaged cakes, packaged cookies, muffins, pretzels, chips. No good and, you know, there are lots of things you can substitute if you're sort of peckish and wanna eat something. Nuts, hummus and carrots, apples and cheeses. Those are things that are healthy for you and can substitute for these packaged ultra-processed foods. You know, one of tests I like to say to people, "Go and get an old magazine with a lot of pictures in it from the early 1960s." You'll have a hard time, you know, even candid pictures out in, of finding obese people or go and get what in the United States we... yearbooks of a school. You know, all the kids lined up. You won't see an obese kid in there. You just won't. And the change has been, you know, what is the change? Is it genetics? Absolutely not. Genes don't change that fast. Ultra-processed foods is a very big component. It's not the only component, but it is the major driver of that change and, you know, we have to get away from it.

Jonathan: Moving on, I think everyone knows smoking is a terrible idea. Even people who smoke, they all know that it's not good for them. But what about vaping?

Ezekiel: It may be better than smoking, but it doesn't make it healthy. We've been studying smoking for decades. More than 75 years ago, I think, was the first, Richard Doll, you know, showed in his epidemiology that smoking was causing lung cancer. We don't have 75 years of vaping. That's the first thing. The second thing is there's some good data about, yes, vaping can get people to quit smoking, but it also can get people to actually smoke, and there's more chemicals in vaping that we don't actually fully understand, and we've already had a couple of new lung diseases caused by vaping. Bad idea.

Jonathan: Is that right? We're seeing, so we are...

Ezekiel: Yeah.

Jonathan: ...seeing diseases. This isn't just, sometimes I feel like, you know, doctors, they always wanna tell you that you can't do something, so the fact everyone's taking up vaping, they have to then tell you that it's a bad idea. But there is genuinely evidence...

Ezekiel: Yeah.

Jonathan: ...that this is bad? There is.

Ezekiel: And now they've taken some of those chemicals that we have been able to identify, but there are hundreds of chemicals in these vapes, and that's not, again, not a good thing to put into your body.

Jonathan: And so let's say your kids are vaping, because you definitely see this explosion in younger people as the...

Ezekiel: Right.

Jonathan: ...cigarettes are gone. How worried should you be about that...

Ezekiel: Yes.

Jonathan: ...versus all the other things that you might be worrying about?

Ezekiel: No, I think that's something you do wanna worry about, and it does point to the fact that the vaping industry has just ripped out a page from the tobacco industry. Get them young, get them hooked, and you'll have them for life, and that's a recurrent revenue stream. And it's really, it's totally exploitative.

Jonathan: Final ones on things you might want to reduce or stop, supplements.

Ezekiel: Okay. Very complicated, and it's kind of like the alcohol story, sometimes good, sometimes bad. So I think in general, and most of the medical profession would say, you should not do supplements. They're a waste of money. They're not good, and especially the idea that some vitamins and minerals are important, maxing them ought to be good. You can get toxic reactions. That's the first thing. What I'm hesitant at, and what you're hearing that hesitance in voice, there are some recent studies that suggest that a multivitamin might actually slow the cognitive decline of old age. You know, you take it one multivitamin a day, no harm in that except the expense. And if it has this positive benefit on cognitive decline, probably worth it. And there are some other population groups that do need some kinds of supplements. Women in folate, who are thinking of getting pregnant, or are pregnant. Vitamin B12 for vegans is another one. People who don't get outside either because of mobility issues or whatever and don't get enough sunlight, you definitely need things like vitamin D. So I think there are some special categories. For the vast majority of your listeners, besides the multivitamin for the reason I said, probably not very useful. For most of these, the biggest harm is likely to be in the checkbook or the wallet, not in the health.

Jonathan: Is this just about spending too much money that has no benefit, or is there actually risks from this sort of wellness explosion around supplements?

Ezekiel: Some of the supplements where you take too much, there are risks. But, you know, let's take protein. Huge push on protein. We're in this sort of protein max moment where everyone has gotta take grams and grams of protein per kilogram. You can actually get gout, for example, from protein. You can create kidney stones depending upon the protein. Bad idea to go way too high into protein max. That is an example of a problem that can arise from too much protein. And, you know, gout used to be a disease of old rich men. You know, Ben Franklin had gout. Why? 'Cause he was eating very rich food, not getting a lot of exercise, hydration not terribly good. And it can happen today, too.

Jonathan: I'd now like to talk about your six rules and what we should be doing to support healthy aging. And I'd like to start with the first one, which is the best rule...

Ezekiel: Yeah.

Jonathan: ...that I have heard in anything around wellness, 'cause I'm afraid you have sort of written a wellness book, Zeke...

Ezekiel: Yes.

Jonathan: ...just so you know. The first rule in your book is, don't be a schmuck. What does that mean?

Ezekiel: Yeah. Don't be stupid. And this is something my father used to say to his three sons very commonly when we were doing something dumb. He would say, hit us on the back of the head and say, "Don't be a schmuck." And I have a cute story in the book about when I bought my first car and definitely was a schmuck and... But there are things we do, right? Life is full of risks. Let's be clear. You don't wanna live a life in Bubble Wrap, and you are gonna take risks. For most of us, the riskiest thing we do is turn the car ignition on in the morning. Driving is a risky activity. I would just say in the United States, the chance of dying over a lifetime is more than one in 100 from a car accident. Smoking and vaping we know are real risks. Not taking your vaccines, despite what, you know, the American Secretary of Health and Human Services said, is a real risk. I mean, the risks of polio, the risks of measles, the risks of chicken pox have all dramatically declined because of vaccines, and people are healthier as a result of vaccines. So get those vaccines. Get the cancer screening tests. But there are other things that are really dangerous for you, and doing them are schmucky moves. So when I was writing the book, when I, that first 35,000 words, I was like, well, gotta be the stupidest thing you can do is BASE jumping. You know, getting in that Michelin Man suit with the wings, no propulsion, jumping into the wind where the wind might smash you into the mountain you just jumped off of. So I looked up the data and, you know, one in 2,700 jumps is a mortal jump. You die, and a lot of the people doing BASE jumping realize they will die by BASE jumping. And it's like, why would you do a sport where the end result is your death? That's schmucky. And then I looked up the data about climbing Mount Everest, and I'm like, holy cow, this is the stupidest thing you can possibly do because all comers, the risks of dying on climbing Mount Everest, it's actually mainly on the descent, is one in 100.

Jonathan: One in 100?

Ezekiel: One in 100. And so it's like, why are you doing this for such a high risk of death? Now, I understand if your focus in life is being a mountaineer and climbing the peaks, but that's a risky activity.

Jonathan: And you mentioned being president of the United States.

Ezekiel: We've had 45 men as president. And four have been assassinated in office, okay? Lincoln, Garfield, McKinley, and John F. Kennedy. Four out of 45, that's a one in 11 chance of dying. Way higher than climbing Mount Everest. And it also turns out there were eight assassination attempts, which were, quote-unquote, I would say, successful. So being president is very risky.

Jonathan: All right. The second one on your list is social relationships, and I think a lot of people listening will be very surprised that this is basically at the top of a list of rules for better health. Can you help us understand?

Ezekiel: That's what the science says. So 2,500 years ago, Aristotle wrote that man by nature is a social animal. And he knew. He understood we're social beings. Our brain is constructed to interact, communicate, collaborate with people. And when I say, you know, so interacting with people, having close friends, spending time with them is the most important thing you can do for your health, they're like, "Okay, I understand it's psychologically important." No, it's biologically important. What goes on in the brain is actually important for your body. So when you interact with someone, it stimulates oxytocin, that so-called love peptide to go up. Dopamine, the reward peptide goes up. The hypothalamus pituitary access down to the adrenal gland decreases your stress hormones. Some genes, if you're lonely, are turned on, and they're not good genes. They're for inflammation and reducing your immune response to vaccines and virus exposure. So lots of changes in your body, and there's some recent studies, very interesting studies in our brainstem, right? The lowest, the oldest part of the brain, there seems to be a very close regulation of social time and alone time, and that when you're having social time, you know, that gets stimulated, but you need to balance it with alone time. Now, all of us have slightly different balances. Some of us are extroverts. We need more social time. Some of us are introverts. We need more alone time. But this balance turns out to be very important for our bodies' happiness and health. And so our entire brain is constructed around social interactions, and it does way more for us. We know that if you're lonely, socially isolated, you dramatically increase your risks of mortality.

Jonathan: So I think a lot of people listening will say, "Well, I'm not surprised to hear that social relationships have a lot of impact on feeling happy." Right. That seems pretty obvious, I think, to almost anybody. But the fact that it's having these physical effects seems much harder to believe, and you're saying at the end, like, literally you will die sooner if you're not having these good...

Ezekiel: Social relationships? You'll increase your risk of dying sooner, absolutely. So there are lots of studies that actually look at this. More than three million people worldwide have been enrolled in studies about social interaction and longevity. And the socially isolated, people who have zero or one friends, don't see friends a lot, those people are much more likely to die in the next few years. So let me give you a study. In the United States, we have something called the Health and Retirement Study where we look at people close to retirement, follow them every few years, examine them, talk about their interactions, et cetera. And in that group, people age 50 and older, the people who are socially isolated or report being lonely, they have a 25% increased risk of dying over the next eight years.

Jonathan: They have a 25% greater risk of...

Ezekiel: Dying in the next eight years. This is why I say it's the most important positive rule. So the oldest running study in the world, as far as I can tell, is the Harvard Adult Development Study, started in the late '30s, then merged with another study in Boston of less privileged kids, and they follow people over time. For 85 years they've been following people, and then the next generation of people. And it turns out the people who live the longest are people with social interactions, who are married and remain married. Very important. And China has emulated this study with 100,000 people, and they check in with them every few years. And it turns out people who, you know, as they get old, do mahjong, have other social interactions, exercise with people, have their family, their kids, their grandchildren come and visit them daily, they live much longer and have fewer health impairments as they live longer lives. So that we know being socially isolated or lonely is the equivalent of smoking 15 cigarettes a day.

Jonathan: 15 cigarettes a day?

Ezekiel: 15. Half a pack.

Jonathan: And so do we understand at all, like, what that link is between the social interaction and what's actually physically happening in our body?

Ezekiel: We don't understand it all. We're beginning to unravel it. In fact, the UK Biobank is one of the big sources actually of some of these data, that if you look at socially isolated people versus people who have a lot of social interaction, like a lot of friends and they see them a lot, that difference, there are about 50 genes that are activated in the socially isolated and are negative that increase inflammation. They actually suppress your immune response to viruses and vaccines, increase your risk of cardiovascular disease. You know, the exact pathways haven't all been worked out. But again, you know, social interactions is gonna stimulate your brain. Seeing people, listening to people, talking to people, revealing yourself. I don't know what people think the mind is, but it's between your ears, and it's encoded in the interactions between your neurons, and those affect the body. We're learning so much more about how that happens. Do we know it perfectly? Absolutely not. But we do know that being socially isolated, being a hermit in Alaska is not good for your health.

Jonathan: What does it mean, like, to have this social relationship? Does that mean I need to have, like, a few really deep relationships to have any value? What does this really mean? Help me to understand.

Ezekiel: You need both. But many of these studies look at close friends, how... People you talk to every other week, you know, at least every other week. People who have known you a long time so that you can have close interactions. You know, these casual interactions are also important for people. We've got a lot of studies. There's a professor at the University of Chicago, Nick Epley, who's done a lot of these studies of asking people to, you know, on a commute, talk to the person sitting next to you on the train or on the bus. People tend to be resistant. "It's gonna be a waste of time. They're not gonna wanna talk to me. I'm not gonna learn anything," you know? Just like, "Gonna be totally boring. I won't be able to get out of it." All of those are wrong, just wrong. Turns out you actually think the time goes faster. You learn something. You are happier at the end of it. All of these things turn out to be... Interacting with other people is biologically what we're driven for. And when you do it, even if you're an introvert, when you act extroverted, you enjoy it more and you feel better. It's things like endorphin release and other positive signs. Dopamine, it's a reward. So I think you need both close relationships, people you can talk to intimately. And, you know, Robin Dunbar at Oxford, you know, has the Dunbar number. You know, close personal relationships, five to 10, no more. You just don't have enough time and frontal lobe experience. Then you have acquaintances, people you have over for dinner, but you might not reveal intimate mistakes you made or other issues. And then there are, you know, people, acquaintances you know, you recognize, you see them after a number of years, you know, up to 150. And most of us don't have more, can't have more than that. You just, A, don't have time, and B, don't have the cognitive capacity to keep track of these people.

Jonathan: I love all of that. I think anyone who knows me knows that I'm quite an extrovert. So I am basically miserable if I'm stuck in the house on my own all day. I get, I can manage about an hour and a half, honestly, Zeke, after which I'm like, "Oh, I need to get up," and like, you know, I... So I...

Ezekiel: Well, we have a recent study, and I'll brag because it's my daughter, who looked at remote work and people who work at home. She just published it in Science. Work at home alone, and they can go for, you know, several days of not seeing anyone, not going outside, not interacting with people. And it turns out that working at home is actually more mental health problems, higher rates of diagnoses, higher use of drugs for mental health problems. So you can be alone, but it ain't good for your mental health and behavioral health. And again, I think people think mental health, oh, that's psychological, it's somehow out there in the ether. No, it's in the brain, and it affects your body. And we know that people who have serious mental health problems, and even mild mental health problems, anxiety, depression, don't live as long.

Jonathan: What would you say to someone who's listening to this who is isolated? And you just sort of said, actually, this is really bad for your health, so that's quite a hard message to land. What advice would you give to them?

Ezekiel: Think about ways you can begin to interact with people. If you can, join a book club. If you can, join some other... You know, maybe you like singing. Join a choral group. Start taking up a musical instrument or an art class, and go to a class where there are other people. Go to a college and take a course or two. Volunteer where you're working with other people. And, you know, you're interacting with people, and you'll regain the social skills.

Jonathan: I love that. Let's move on to the third rule, which is staying mentally active. What does that mean?

Ezekiel: We all are cognitively sharp, and our cognitive function, our brain power, as it were, goes down over time, and it begins to go down late 30s, early 40s. It's kind of inevitable. So what are the things that we can do to postpone the time when, you know, we will have lost so much brain power we will become cognitively impaired or, God forbid, demented? The first thing you can do, get more education. If you're listening and you're in your 20s, go back to school. It's really good for your brain. The second thing is there are four vaccines you can get, and I think this is very underappreciated. Four vaccines you can get that are actually good at postponing cognitive decline and dementia. One is the shingles vaccine. Amazing vaccine. You get two shots at 50, and you're really covered for life. It prevents a very painful illness, but it also decreases your chance of cognitive decline by about 20%. The pneumococcal vaccine prevents a pneumonia. Get that. DPT, diphtheria, pertussis, tetanus vaccine. Get that. And the last one is your annual flu shot. Also, the more you get of them, the less a cognitive or the postponement of cognitive decline.

Jonathan: I think people will be really surprised to hear you jump from staying mentally active, and they are expecting you to say, like, do the sudoku or something.

Ezekiel: No.

Jonathan: And you've gone straight to take four vaccines. Yeah. Could you just help us to understand that for a minute?

Ezekiel: Yeah. It probably suggests that viruses and the reaction to viruses have a role in cognitive decline, and that if you want to prevent cognitive decline, taking a vaccine that decreases the chance that the viruses, in the case of shingles, will reactivate, or in the case of flu, you'll be infected by a flu, is probably a good thing to protect you. We're increasingly learning that vaccines are related to serious illness. Cancer, I'm an oncologist, right? HPV and cervical cancer, HPV and oral cancer also, right? That is... So we see these vaccines causing serious illness. We now know that Epstein-Barr virus causes some cancers, and they may be related to other kinds of cancer. So it's not surprising that they're related to decline or inflammation in the brain that probably leads to cognitive decline and dementia. Then I would say keeping yourself mentally challenged is super important, especially as you get old and as you retire. So taking up new activities, musical instruments, learning languages, and things like that, really important. I personally, about a little more than a decade ago, began a commitment to myself of every year I'm gonna do something new and out of my wheelhouse that's not related to my career or something I've done before. So I began making chocolate about 15 years ago. I collaborate with a chocolate maker, learn. You know, I've gone to harvest the cacao, ferment it, dry it, roast it, and do all that stuff. I've now made four bars. Last year I began keeping bees and harvesting honey. So there's a lot of things you can take up, keep your mind challenged. You know, Winston Churchill, painting and doing art is a very good one. Volunteering in school, so you teach kids. One of the most challenging issues is retirement, and it's not uncontroversial, but in general, retirement is probably not good for your brain. Going to work has very important things. You keep a schedule. You get up. Other people are depending upon you. You have challenges at work that you have to navigate and solve. You have a friendship group at work and social interactions that you have. And when you retire, you've got all this free time, 40, 50 hours a week, and what are you gonna fill it with? Turns out, unfortunately, at least in America, a lot of that time's filled with one of the worst passive activities you can do, watching TV. And that actually is not stimulating your brain, not challenging your brain. So you have to consciously plan retirement very well to keep the social interactions, to keep being challenged, to keep the schedule. And I think that's something we don't actually... You know, we worry about, "Should I retire? Will I have enough money?" We should worry, "Should I retire? How's it gonna affect my cognitive function?"

Jonathan: Moving on to number four, and four is all about what you eat.

Ezekiel: Yeah.

Jonathan: We obviously talk a lot about that on this podcast. If you're gonna say it in a very simple way sort of your principles for eating well?

Ezekiel: So the first two we've already... stop with the sodas and stop with the packaged sweets. The positives go to something that I know this podcast is really focused on, which is gut health. Over the last ten, 15 years, we've become much more appreciative of the microbiome in the body, and just for your listeners, there are 100 trillion bacteria in your gut. That's more cells than in your body by a factor of about three. They're there for a reason. So eating to make sure the microbiome is actually healthy is super important, and healthy usually means a good diversity of bacteria there. And so I'm a big proponent, if you do only two things related to food, one is fermented foods, yogurt, cottage cheese, good alpine cheeses, kimchi, sauerkraut. Those are really important for your gut, and eating them is, I think, really important. The second part is those bacteria need fiber to grow, and so you've got to eat more fiber. That fiber is very important for the microbiome and to have more diverse microbiome grow. I don't know the data in Britain, but in the United States, the vast majority of people, ninety-three percent of people don't get enough fiber. They don't eat enough fruits and vegetables. This is very important for people to add to their... So if you do only four things, those are the four things to do. And then there's many other things. We probably all need to reduce the amount of meat protein we get. Increase or plant protein is a good idea. Eating organic is good, not 'cause it's got better nutrients, but because the pesticides, as I like to say, you know, what are the pesticides there for? They're to kill bacteria and other pests, right? When they go into your mouth, they don't stop being pesticides. We don't know what they're doing in the gut, and it's probably not a good idea. Now, it costs more, we recognise that, and you might not be able to afford it. But if you can afford it, it's a good thing to do, and I think we should really be pushing our food system in that direction.

Jonathan: The fifth one is exercise. Yeah. So although you were quite tough on exercise at the beginning, it's fully made it into the list. And so what do you mean by exercise?

Ezekiel: Exercise is good. Just being obsessed by it is not good. There are three kinds of exercise we really all need. One is aerobic, getting your heart rate up, getting your breathing rate up. Very important for decreasing your risk of cardiovascular disease. Also happens to make you happy through endorphins. So that's very important. And again, we talked about it, about two and a half hours of vigorous exercise each week. My preferred... I used to be a runner, but now I'm a big bicyclist. There are lots of things you can do to fill that. You can row, you can swim, you can mountain climb or hike vigorously. The second one is strength training, and this is especially true for your listeners who are over 55 or so, where muscle mass begins to seriously decrease. So we lose about 10% of our muscle mass every decade. That's a challenge. We don't want to do that. We want to keep vigorous. We don't want to bend over. We don't want to not be able to get out of a chair. And there you have the strength training is important. Now, if you swim, you know, you get strength training on the upper body. If you ride your bike or run, you get strength training in your lower body, but you need to balance the whole body. And the last one is flexibility and balance. Every morning I do 20 minutes of yoga, really important to keep that flexibility and balance going.

Jonathan: And I think the balance and flexibility is interesting because often when I have scientists on the show, they talk a lot about the mix between the sort of strength and aerobic, but they don't necessarily talk about sort of balance. Why did that make it into this list for you?

Ezekiel: Well, one of the dangers of growing older is fractures and hip fractures. And being more balanced and being more flexible is really good at decreasing that risk. It also loosens up the muscles so that you don't get contractures and things like that. And like many things, you can be social about it, and you can actually have fun.

Jonathan: Wonderful. And finally, we come to the sixth and final one, which is sleep. So how much should we be aiming for?

Ezekiel: So I used to have friends and yeah, you probably did too, who thought sleep was a waste of time. You know, it's like, "What am I doing? I'm just sleeping." The fact that we sleep is the best response to that idea. Again, evolution has this way of getting rid of things which are a waste and aren't good, and sleep is a really dangerous moment. You're unconscious. All of the predators out there are willing to jump on you. So that we preserve sleep means it's biologically necessary. It's important to clean out your brain. It's important to solidify your memories and move them from the hippocampus to the frontal cortex. It's important for proteins to be rejuvenated. So you need sleep. Now, there are some people who are genetically short sleepers, right? They're 1% of the population. They need four hours or something...

Jonathan: You know, not many people. Yeah, yeah, right?

Ezekiel: That's an outlier. You're not an outlier. Just assume you're average. Average is somewhere around six and a half to eight hours of sleep a night or nine hours. And that's what's important. Now, you also need the right mix of sleep, rapid eye movement sleep, deep sleep. The problem with sleep is, first of all, we've changed our environment, so it's no longer dark at night. So you got to make your room dark to make it conducive. We have a lot of stimulants, whether it's caffeine or alcohol. You got to stop drinking those at least eight hours before sleep. There are various other things you can do. You can cool the room down. Don't look at your screen. Get into a routine of going to bed every night. Now, that's not possible for all of us. I've just flown to London, right? It's like, well, there's a big time difference between the East Coast and London, and you're out of whack. That's right, and, you know, it'll take a problem. If you have to stay up late at night, it's important to sleep the next day and get those extra hours. Actually, the body responds to that rebound sleep positively. It's a good thing.

Jonathan: And Zeke, like, how important is sleep really? Because, you know, I feel I hear these two completely conflicting messages, which is, one, you know, if you don't get eight hours sleep every night, then, you know, you're gonna die decades earlier. It's the worst thing that could possibly happen to you. It's, like, more important than anything else. And on the other hand, you know, I can think about probably a bit the way I, you know, when I grew up, my dad's like, "Well, you know, you should just, you could just power through it."

Ezekiel: Powering through is, that's not right. You become the equivalent of drunk if you lose sleep. And the risks begin to be high. Your judgment is bad. You take more risks. You're terrible behind a car. So that is wrong. Powering through, yes, maybe if you have to power through for one night, all of us have done it, but don't make it a habit, and don't create a job that requires it. You do need sleep. Is it the most important thing? No. I've already said social relations are more important than sleep. The challenge with sleep is First of all, we are doing a bad job of it. Most of us don't get enough. And we can't will ourselves to do it. Well, everything else I've said, you know, social interaction, you can will yourself to talk to people. You can will yourself to take up a new project, new cognitively challenging activity. You can will yourself to get on the bicycle 20 minutes three times a week. You can't will yourself to sleep. It's counterproductive. Willing yourself to sleep will be a guarantee you'll stay awake. So that's the big challenge. And all of the medications made, whether it's Ambien or Halcion or melatonin, don't work. So stop taking them, by the way. Just they have side effects and-

Jonathan: So sleep medication doesn't work?

Ezekiel: None of them. Okay? I used to take Ambien 'cause I wasn't getting enough sleep. What I would find is, you know, I got up in the morning, I was a little groggy. That's exactly what I was trying to get the sleep for, is to prevent the grogginess. If I take the medication and I'm groggy, it's counterproductive. The American Academy of Sleep Medicine says the only thing proven is cognitive behavioral therapy for insomnia, figuring out why you're not sleeping. I know for me personally what it happens to be. It happens to be if I've got a work dilemma or I'm writing something and I'm turning it over in my head trying to figure out, you know, what do I exactly want to say? What's the right phrasing here? That's what keeps me up at night. And so you have to figure out a method to sort of put that to the side, and that's what cognitive behavioral therapy can help you with. Creating a sort of mini ritual around sleep. Plan to watch the TV show you like, then, you know, do your bedroom or bathroom routine and then get into bed and maybe end by looking at an actual book, at the paper and pen book. And I know for myself that that's the routine I've adopted. I get into bed and, you know, sometimes I can read for 10 or 20 pages, sometimes it's just a few pages, and I know when I'm done because I've reread that paragraph two or three times and I'm not sure what it says. My eyes are sort of hanging down and it's like, all right, now's the time. But you should know that sleep is, you know, we get the sleep impulse when adenosine, a chemical in the brain goes up. And if you go to sleep and then wake up, which some of us do, that adenosine has gone down and it gets hard to go back to sleep, which is one reason, again, napping can be good for you. Power naps actually are good. But power naps after 2:00 PM or so actually obstruct sleep because you use up that adenosine, and you know, it's hard to get it back to put you to bed.

Jonathan: If you were going to advise a listener who isn't doing any of these things and you were going to say like, "What's the one thing that you should focus on and try and do first?" What would you tell them?

Ezekiel: Dinner parties. So you have a dinner party. You cook and you both have good, healthy food because you've cooked it and you've challenged your mind 'cause you're adding a new recipe and you're figuring out how to do it right. You have people over, so you've got social connections. You're challenging your mind with a good conversation. And when it's all over, you go out for a walk, so you get some physical activity. This is like you've done almost everything in wellness. All of those elements are key to wellness, and it's the kind of thing you can do, you know, once a weekend or... And you'll be happier.

Jonathan: Zeke, I'd like to try and do a little summary. And we've covered a lot. You know, the thing that really sticks in my mind is you're saying, "Don't do 10 hours of vigorous exercise a week. What a waste of time. It's not going to improve your health." Because actually the data says you need to do about two and a half hours of vigorous exercise a week, and after that, sort of the benefit plateaus, it stops, and some more moderate exercise instead. So that's quite exciting. I love that. The second thing that I would take away at the end is like, have a dinner party. It's like the super activity that solves almost everything that supplements are mainly a waste of money, and peptides are worse than that. Yes. They could really be dangerous, so don't be a schmuck. Don't do that. On alcohol, you're not telling us that we have to give up, even if, you know, often the medical advice we're hearing from governments now is sort of none. But for you it's, like, three to four drinks a week, so this is quite a small amount. And then we come onto your six rules. The first is, don't be a schmuck. So don't climb Everest, don't smoke, don't be president. The second is social relationships, and for you, this is so important, and I guess this is the central message. Yeah. You know, that you've shared today and you talk about in the book. And if I understood this rightly, you said there's this research looking at people who are socially isolated over the age of 50, and they have a 25% greater risk of dying in the next eight years.

Jonathan: Correct.

Jonathan: And so that's an enormous difference from something that sort of seems crazy because it's not, like, something you're eating or a drug. It's literally just not being with people. And you shared a bunch of tips, but your number one that came in repeatedly was, like, join a book club because you manage to not only deal with the social relationship but also your third rule, which is staying mentally active, and that's really important. Retirement is bad for you because of that, so actually everything that we're sort of like, like retire early. I spent a lot of time working in France, you know, a decade ago, and it's like, it's the home of retiring early. You're like, "No, this is bad for you." But I think the most surprising thing you said is, take these four vaccines to reduce the risk of dementia, so actually it's not about reading a book. And I think you said shingles, pneumonia, DPT, and your annual flu shot. And that actually there is hard data that suggests that if you do this, you actually reduce your risk of dementia. Have I got that right?

Ezekiel: Yeah.

Jonathan: Which is extraordinary.

Ezekiel: You're doing well.

Jonathan: The fourth is about what you eat. I think anyone who listens to this show regularly won't be surprised, but I think just interesting how much, like, what you say is sort of in line with, I guess, sort of this gut health focus that seemed pretty radical, you know, eight years ago. And if you're gonna make it really simple, you're saying, "Stop the sodas, reduce the ultra-processed food, focus on your gut health." Fifth, we have exercise. So despite the whole book being triggered by, like, anger about this book about exercise, you are actually saying exercise is important. Oh, yeah. But it's not like the only thing and it's not number one. And you want to have these balance of these three types of exercise. Aerobic, get your heart rate up, that's really important for your heart health. Strength training, particularly because as you get older, you're losing the muscle mass, and if you want to be able to get out of a chair and, like, have a good life, you need to have muscles. And thirdly, really interestingly, you want this flexibility and balance, because actually the thing that's really dangerous as you get older is that you fall, and then you break something, and then you lose mobility. And I'm sure we all have loved ones where this has happened, and it is really heartbreaking to see. So you're saying think about balance and flexibility early to help protect that. And finally, number six, focus on sleep. That does really matter, and it's also the only one where, in a way, getting too obsessed by it can make it harder to sleep, and I think lots of people listening to this will experience that. And I think the most, you know-- The thing that really struck me, as you said, is like, don't take sleep medicine. So if you're currently taking sleep medicine, stop. You know, the evidence is that it doesn't work, so stop. You can do this cognitive behavioral therapy, and ultimately this is figuring out how to build routines and think about this in a better way. But when you look at all of this together, you know, my big takeaway is that for most people, the thing they should really be embracing is these social relationships, because that is probably the thing that if you're obsessing about all of these other ways to improve your health, you're sort of losing this thing that is really good for your health, but also just, you know, great for your quality of life.

Ezekiel: Yeah. You get a start first.