#57–Rick Rubin: collaborating with the greatest living musicians, & his personal weight loss story

Maffetone came to live with Rubin for roughly two years, overseeing daily training progression from the treadmill to stair-climbing (3-flight loop in Rubin's home) and eventually jogging. The heart rate monitor was worn at all times during exercise. The target zone was later refined as Rubin's fitness improved. Attia characterizes Phil's approach as combining exercise with circadian rhythm correction (shifting from an all-night / sleep-all-day schedule to normal waking hours), dietary carbohydrate restriction, and the introduction of fish and eggs as the first animal proteins.

Dr. David Heber at UCLA used indirect calorimetry to measure Rubin's exact TDEE (2,300 kcal/day) before prescribing the 1,400-calorie-per-day protocol. The initial dizzy spell lasted three days; after that Rubin felt fine. The protein target was set to his goal weight of ~187 lbs (roughly 200 g/day). Attia notes this approach received backlash when some patients on high liquid-protein diets experienced complications, but argues those failures were due to unsupervised use in people with contraindications, not the approach itself.

The protocol evolved organically at Laird's training compound in Malibu with a rotating group of professional athletes (football, basketball, hockey players plus local fitness enthusiasts). Rubin transitioned from a man who could not do one push-up to doing 100 consecutive push-ups over the course of the 5–6 year transformation. The progression from Laird's initial program to the full underwater protocol took approximately 2 years.

Attia's comment to Rubin after the scan: 'all that stuff I was saying about deadlifting, scratch that — you are not lifting a heavy weight until we get this resolved.' This is clinically instructive: heavy compound lifts (Valsalva maneuver + acute blood pressure spike) in a patient with critical aortic stenosis and a 6.6 cm aortic root are a potentially fatal combination. The case also illustrates Attia's clinical posture: pushing for the higher-resolution test even when the patient seems healthy and asymptomatic.

Rubin, a needle-phobic patient who had specifically requested no opiates before his open-heart surgery, achieved opioid-free recovery from one of the largest cardiac operations performed. Attia describes the standard surgical objection ('patients in pain don't move or breathe deeply, causing complications') as addressable with proper epidural technique rather than opioids. The post-op atrial fibrillation Rubin developed (~10% rate after cardiac surgery) was unrelated to the pain management approach.

Rubin describes this as the core of his production philosophy: 'if you're meditating with the objective of I'm gonna sit here for the next thirty minutes and that's all I'm gonna do, at the end of that thirty minutes you've succeeded. There was no more to it than that.' Attia explicitly mirrors this to how he coaches exercise compliance — defining success as showing up, not hitting a performance benchmark. Rubin stuck to a medically austere dietary protocol for 14 months and socially managed it easily ('you would just order appropriately when you would go') because the process was the goal.

Rubin describes his depression as a two-year period where he tried 'everything I possibly could to feel better — psychiatrists, psychologists, acupuncture, herbal remedies, massage, diet changes to better support brain chemicals — everything short of taking drugs.' Guided meditation was the one form of contemplative practice accessible to him at the nadir. The depression was eventually broken by Remeron (mirtazapine), which he took for a defined period and then tapered off.

Attia makes this observation while noting that Rubin was 'experimenting with meditation' at the time of the interview — an indicator that he was just beginning a formal practice. Attia draws the connection: 'it's a one-pointed activity where the other problems of the world don't come with you into the ice.' Rubin confirms: 'it's a forced meditation, you don't have to do anything but survive, but because of that you are very present and in the moment.' The sauna variant produces a similar effect via heat-stress, which Attia had used earlier in his interview with Tim Ferriss.

Attia's post-hoc hypothesis: Rubin was likely glycogen-overloaded and hyperinsulinemic. Maffetone's zone-2 training probably fixed fuel partitioning and resolved much of the hyperinsulinemia — explaining why Rubin felt dramatically better on Phil's program even though he only lost five pounds in two years. The real metabolic block was glycogen saturation in liver and muscle, which requires active calorie restriction and carbohydrate reduction to deplete. Only once the UCLA protocol imposed a caloric deficit deep enough to drain glycogen did significant fat loss begin.

This is consistent with modern chronobiology: circadian misalignment independently drives insulin resistance, cortisol dysregulation, and leptin insensitivity — all of which would further impair fat loss. Maffetone's insistence on normalizing sleep timing before significant weight loss occurred suggests his clinical model incorporated what we now understand as circadian medicine.

Attia's framework: 'I'm actually convinced now I don't think I was convinced of this even two years ago or a year ago — I don't think one can lose weight when the liver and the muscles are full of glycogen, that has to be depleted. The two quickest things you can do are to exercise and to restrict calories, and within the calories, carbohydrates are probably the most important to restrict.' This has significant implications for clinicians managing resistant-weight-loss patients.

Attia explains the anatomy: the aortic valve normally has three leaflets (tricuspid); Rubin was born with two (bicuspid). Bicuspid valves are more prone to calcification, which narrows the opening (stenosis). Below a critical threshold of cross-sectional area, sudden death risk rises sharply. Separately, whatever genetic factors caused the valve defect also caused abnormal collagen in the ascending aorta, leaving it prone to dilation and dissection — which at 6.6 cm carried a risk of fatal tear. The surgery required circulatory arrest, and the operating team's speed in executing it was critical to brain safety.

During cardiac surgery requiring deep hypothermic circulatory arrest, the brain is deprived of its normal blood supply. Standard protocols rely on hypothermia and brief interruption windows. The neuroprotective literature on methylene blue — working via mitochondrial electron transport chain Complex IV stimulation — suggests it could reduce ischemia-reperfusion injury during these windows. Attia's regret is not academic: he publicly updates his view mid-episode, modeling the scientist-not-defendant mindset he often advocates.

The standard argument for opiates is that under-treated pain leads to immobility, reduced deep breathing, and thus higher infection and pulmonary complication rates. Attia's position: a well-placed epidural plus NSAIDs and acetaminophen achieves equal or better pain control without the sedation and respiratory depression of opioids, enabling the movement and breathing that actually reduce complications. Rubin, a needle-phobic non-drug-taker who had specifically requested no opiates, achieved this outcome after one of the most invasive cardiac operations possible.

The protocol evolved iteratively: it began as merely walking heavy weights along the pool bottom, then Laird dreamed up a lighter-weight version (10 lb dumbbells) where one breath per rep allowed jump training, backflips, and eventually 50+ distinct exercises. The logic: weights light enough to allow ascent for air, heavy enough to sink you back down. Immersion in cold water (ideally 66-72°F for marathon swimming; Rubin's pool was 'cold but not freezing') suppresses lactic acid accumulation, while hydrostatic pressure at 14 ft provides structural support allowing heavier loads relative to on-land performance.

Attia draws the comparison from his own sauna experience: 'the conversations that happen in the sauna are really good — it helps to turn off a part of your brain that's more guarded, you're preoccupied with survival.' Rubin, who was only beginning formal meditation at the time of the interview, confirms the insight — the ice bath is 'a forced meditation, you don't have to do anything but survive, but because of that you are very present and in the moment.'