Outlive: The Science and Art of Longevity
by Peter Attia, MD
In Outlive, Peter Attia discusses the importance of longevity and healthspan in our lives. The book emphasizes that chronic diseases, such as heart disease, cancer, neurodegenerative disease, and type 2 diabetes, are significant causes of "slow" death. These diseases, referred to as the Four Horsemen, need to be proactively addressed.
Longevity consists of
- lifespan (how long you live) and
- healthspan (the quality of your years).
To achieve a better future, it's crucial to start taking action now & to think long-term.
Maintaining physical, emotional, and cognitive health is vital for overall well-being.
Medicine 1.0 to 3.0
Attia introduces Medicine 3.0, which emphasizes prevention and proactive measures rather than traditional treatment (Medicine 2.0).
We need to proactively intervene against “slow death” causes. Coronary issues (plaque build-up in coronary arteries, leading to issues with blood transfer to heart muscle) happens over a long timeframe, but we usually don’t intervene before it’s too late (i.e. heart attack).
It’s not that medicine 2.0 hasn’t worked. It has. Very effectively, actually. Just not against slow causes of death (see Horsemen from earlier: neurodegenerative disease like Alzheimer’s, heart disease, diabetes type 2, etc.).
Medicine 1.0 goes back to Hippocrates and goes until we started finding out we should use sterile environments, invented penicillin, etc. This is the longest period by far.
Medicine 3.0 'medication' is taken daily. It's an improved lifestyle.
The approach to longevity involves three parts: objective, strategy, and tactics.
Strategy without tactics is the slowest route to victory. Tactics without strategy is the noise before defeat.
— Sun Tzu
For objectives, ask yourself:
What is your goal for the last decades of your life?
What would you like to do? Be able to do?
Figuring this out helps guide what is necessary to accomplish it.
We have to start early. The gravitational pull of aging is strong, so ideally you either maintain or improve as the decades go on.
If you don’t want to spend your last decade as so many of our elders do today: frail, weak, depressed, it’s time to start intervening. (Attia: marginal decade)
When you set goals for old age, you need to account for your natural decline. Want to be able to pick up your grandchildren? You can imagine how much a small child weighs. But now account for the decline. You need to be able to basically goblet squat a lot more than just the weight of the child now, so you can lift the child later. E.g. lifting a 20 pound suitcase overhead later means 40-50 now.
The point of this book isn't just to say do this & this, but to take a three-step approach to longevity, starting at your objective, then figuring out our strategy, and finally talking tactics. Our objective guides our strategy. Our tactics flow from our strategy.
Strategy is very important. It allows you to find new tactics when your current ones don’t serve you. If you only focus on directives when trying to optimize your health, you’ll end up scrambling around, never getting anywhere.
The five broad domains of tactics in Medicine 3.0 include:
- Emotional health
- Exogenous molecules (drugs, hormones, or supplements)
Exercise is by far the most potent longevity “drug.” No other intervention does nearly as much to prolong our lifespan and preserve our cognitive and physical function.
No pills or medications will ever improve your health as much as exercise.
- lower all-cause mortality
- better cognitive and emotional health
In fact, simply going from 0 weekly minutes of exercise to 90 can reduce your risk of dying from all causes by 14%.
Exercise is critical for both cognitive and physical function — it prevents the decline of both better than any other intervention. We also feed better when we exercise, so it likely has effects on emotional health as well.
To improve longevity, Attia suggests setting high goals for aerobic and strength training, and maintaining balance through stability exercises.
A balanced approach to exercise consisting of aerobic endurance, strength, and stability training helps maintain overall health as we age. In particular, we break down exercise into:
- aerobic efficiency
- peak aerobic capacity
Increasing your limits in each area is necessary to reach your limit of lifespan & healthspan.
Endurance exercise is good. Helps mitochondrial efficiency. And inflammation and oxidative stress. In general, the more aerobically fit you are, the more energy you'll have. A good approach is to do both long, steady endurance work (jogging, cycling, swimming) in zone 2, and max aerobic efforts (where VO2 max comes into play).
Strength training is simpler: just do resistance training. Not just to build muscle, but to build strength as well.
Stability is like the solid foundation that enables us to do everything else without getting injured.
Targeting VO2 max (a marker for longevity) through specific training sessions is recommended. Most of the top riders in the Tour de France will have a VO2 max in the high 70s or low 80s, for reference. The highest VO2 max ever recorded is 97.5 ml/kg/min.
Building muscle mass and strength is vital for long-term health.
Athletes who engage in frequent movement and diverse activities can slow the progression of Parkinson's disease.
Zone 2 training improves cognition and helps prevent Alzheimer’s.
Better grip strength correlates with a lower risk of dementia. Even crazier, there seems to be nu upper bound to this relationship. The better your grip strength, the lower your risk of dementia.
Exercise improves glucose homeostasis and vascular health, reducing Alzheimer's disease risk.
Sleep is essential for brain health and preventing dementia.
Good oral hygiene can also lower inflammation and potentially Alzheimer's risk.
Attia proposes the concept of a "Centenarian Decathlon" – activities one would like to perform well in old age.
Protocol — zone 2 training
If just beginning, you need 2x30min zone 2 weekly.
If not a beginner: 4x45min weekly. Or three hours in total.
People training for marathons etc. obviously need more.
Attia spends 1h 4x weekly riding his stationary bike at his zone 2 threshold.
Zone 2 training can help raise VO2max, but the best way to improve it is through VO2max training. These are high intensity efforts (for minutes), but less than an all-out effort.
A goal to strive for:
Elite VO2max first - for your age & gender. Then for the same, but 2 decades younger (although, being in my 20s, this may be better to aim for later…).
Protocol — VO2 max training
3-8 minutes per rep for 6-8 sets.
Each rep is followed by four minutes of easy work - enough to get your HR to sub ~100 bpm.
4 min hard, 4 min easy x 8.
Note that you need to be almost completely recovered between sets. If 4 min easy isn’t enough, wait longer. You want to be as close to fully recovered as you can to get max benefits from the next set.
You also need to ensure proper warming up and cooling down after these intense sessions.
Protocol — Strength & resistance training
Your ability to carry heavy things is important.
A way to train this is rucking. Literally a rucksack with weights in it. If you do this, make sure to go up & down hills during training. A good goal is 1/3 or 1/4 of BW in weights.
Attia structures his training around exercises that improve:
- Grip strength
- "Attention to both concentric and eccentric loading for all movements, meaning when our muscles are shortening (concentric) and when they are lengthening (eccentric). In other words, we need to be able to lift the weight up and put it back down, slowly and with control. Rucking down hills is a great way to work on eccentric strength, because it forces you to put on the “brakes.”"
- Pulling motions (at all angles, from overhead to in front of you)
- Hip-hinging movements, e.g. deadlift, squat, step-ups, hip-thrusters, etc.
Training grip strength is immensely important.
You can improve it by doing farmers carries for 1 minute when you exercise.
Your aim is to carry half your body weight in each hand.
Protocol — Stability
- Breath is important. Mentions DNS as worth checking out (dynamic neuro…something). There are various exercises to strengthen diaphragm and such. Beth Lewis is quoted as an expert here.
- Our feet perform a critical role as well. Can do toe yoga - see video.
Improve your balance to improve your longevity.
Stand on one leg, with the raised foot in front of your body. A nice goal is to be able to do it with eyes closed for 10-15 seconds.
Metabolism is the process where our body breaks down nutrients for use. In a metabolically healthy person, nutrients are processed and directed properly. In an metabolically unhealthy person, excess calories can cause harm if the nutrients are sent to the wrong places.
When you eat a doughnut, your body decides how to use its calories. The carbohydrate in the doughnut can turn into glycogen, a stored form of glucose. About 75% of glycogen goes to muscles and 25% to the liver. An adult male can store around 1,600 calories worth of glycogen, enough for two hours of vigorous exercise. If you don't refuel during a long activity, you may run out of energy and... not feel great.
Metabolic syndrome, a cluster of health issues, plays a significant role in one's overall wellbeing.
Maintaining a healthy metabolism is crucial to preventing the development of chronic diseases.
Metabolic dysfunction, including insulin resistance and type 2 diabetes, increases the risk of chronic diseases.
Reducing metabolic risk factors such as visceral fat and optimizing blood pressure are essential for cancer and heart disease prevention.
Metabolic syndrome is defined in terms of the following criteria — you have it if you can check 3 or more of these off:
- high blood pressure (> 130/85)
- high triglycerides (> 150 mg/dL)
- low HDL cholesterol (< 40 mg/dL in men or < 50 mg/dL in women)
- central adiposity (waist circumference > 40 inches in men or > 35 in women)
- elevated fasting glucose (> 110 mg/dL)
This is, for sure, not something you want.
Obesity isn’t THE problem. It’s just a symptom of other problems.
That’s not to say it isn’t a big problem. It is. But it’s not the whole thing.
You don’t need to be obese to be metabolically unhealthy.
Visceral fat is linked to an increased risk of cancer, cardiovascular disease, and type-2 diabetes. To lower the risk of these diseases, it is essential to improve metabolic health, maintain a healthy weight, and avoid excess consumption of fructose.
Our bodies can store a large amount of calories as fat — and where to store them is primarily managed by insulin. If you are exercising, the energy is often given to the muscles. If you are a sedentary person, it gets stored as fat.
Subcutaneous fat, stored under the skin, is not harmful in itself; the problem arises when excess energy is stored in visceral fat, located amongst organs, leading to inflammation and health risks.
Example — 40 year-old male with 20% body fat (average):
Even if just 4.5 pounds of that is visceral fat, you would be considered at exceptionally high risk for cardiovascular disease and type 2 diabetes, in the top 5 percent of risk for your age and sex.
Reducing risk of heart disease
A major focus of the book is the prevention of heart disease, which is the leading cause of death.
But it doesn't have to be. We can reduce the risk.
To reduce one's risk, it is necessary to lower levels of apoB particles such as LDL, VLDL, and Lp(a), which are causally linked to atherosclerotic cardiovascular disease. In some cases, this requires the use of medications such as statins in conjunction with diet and exercise.
Attia believes you can't lower apoB nor LDL-C enough, provided there are no side effects from treatment. You simply want it as low as possible.
The reason, basically, is to avoid plaque build-up, which could lead to heart disease.
IIRC, LDL-C can get stuck in your arteries, leading to the build-up—but don't quote me on this. The keyword here is atherosclerosis.
Also, watch out for apoB and Lp(a).
Lp(a) is sneaky. You can get tested for it.
Likewise, you can get an apoB test. And a calcium test (to test for calcification of plaque—which is a way the body deals with the build-up.).
You’d be scared to know just how young people start getting the buildups: 15 or older. 1/2 heart issues for men occur at 65 or below. 1/4 at 54 or below. You aren’t safe just because you’re in your 20s, 30s, 40s.
If we all maintained the apoB levels we had when we were babies, there wouldn’t be enough heart disease on the planet for people to know what it was.
If you smoke, stop.
Also, you want optimal blood pressure. It's important to fight against cardiovascular disease.
Reducing risk of neurodegenerative disease
Exercise, particularly endurance exercise, is crucial for maintaining metabolic and vascular health, reducing inflammation and oxidative stress, and staving off neurodegenerative diseases like Alzheimer's disease.
Additionally, good sleep hygiene can help prevent dementia by allowing the brain to heal and rid itself of cellular waste.
To improve overall health and protect against cognitive decline, Attia suggests focusing on four main principles:
- What's good for the heart is good for the brain - prioritize vascular health.
- What's good for the liver (and pancreas) is good for the brain - promote metabolic health.
- Start early in prevention and think long-term in risk assessment.
- Exercise is the most powerful tool for preventing cognitive decline.
Another potential tool is the use of saunas. The protocol would be 4x weekly, each session being at least 20 minutes, at 179 degrees Fahrenheit (82 degrees Celsius) or hotter.
This seems to reduce the risk of Alzheimer's by ~65%.
Nutrition matters – maintaining a balance of calories and nutrients is key. The Mediterranean diet is the closest to a research-proven “better” diet, with studies suggesting consuming nuts and olive oil is beneficial.
The number of calories we eat matters. Probably more than what you eat.
Nutrition is rather simple:
- Don't eat too many calories, nor too few
- Consume sufficient protein & essential fats
- Obtain vitamins and minerals you need
- Avoid pathogens like E. coli and toxins like mercury or lead
Beyond that, we know relatively little with complete certainty.
Regarding nutrition, Attia underlines the need to consume an adequate amount of calories and nutrients without going to extremes, avoiding junk food, and ensuring a high-quality diet.
The optimal diet varies for each individual, and experimentation is necessary to find the right balance of macronutrients - alcohol, carbohydrates, protein, and fat.
Protein is critically important.
The recommended protein intake varies from person to person but generally falls between 1.6 g/kg/day to 2.2 g/kg/day, and it's advised to spread this intake over four meals a day.
Consuming healthy oils, such as olive oil, avocados, and nuts is encouraged while reducing omega-6-rich oils like corn, soybean, and sunflower oil. Prefer monounsaturated fats like the ones mentioned above (extra virgin olive oil, macadamia nuts, avocados, etc.).
Fasting should be approached carefully and tailored to individual needs.
Although fasting can provide certain benefits, the book suggests that it is not recommended for everyone, and if it is used, it should be done carefully, deliberately, and in consideration of individual circumstances.
Fasting induces autophagy, which is like a cleaning process. It can be induced both by exercise or fasting. It might be helpful against Alzheimer’s.
Fasting can provide benefits such as improved insulin sensitivity, reduced hunger, and improved cellular health, but it is not recommended for everyone. Prolonged fasting can lead to muscle loss and reduced activity. Time-restricted eating can be more useful as a disciplinary measure, rather than a long-term solution to healthy living.
Fasting over long periods of time has many positive effects on the body and health.
Short term: Insulin drops. After 3 days, fat is mobilized (ketosis…), and hunger is reduced.
Long term: mTOR is turned down (mTOR is pro-aging, pro-growth, so this is good), autophagy (cellular “cleaning” process) is activated, and FOXO cellular repair genes are activated, all of which can promote longevity.
Despite these benefits, fasting is not recommended for all patients. Restricting the time you allow eating (shortening your eating window) with Time-Restricted Fasting can reduce overall caloric intake with less hunger, but isn't effective for long-term benefits. It can lead you to missing protein targets, and can easily lead to overindulgence during your short eating window. However, it can help reduce late-night snacking & meals.
It's more important to eat enough to maintain muscle and activity levels — so prioritize that over fasting.
Fasting can be good for overnourished, i.e. overweight, people. Do not limit calories at the expense of protein if you are undermuscled.
Sleep is essential for overall health, with poor sleep being linked to metabolic dysfunction, increased risk of heart attack, and hormonal imbalances.
Sleep is crucial for short-term performance and long-term health. Poor sleep can lead to increased susceptibility to illness, metabolic dysfunction, hormonal imbalance, and cardiovascular issues. Chronic sleep debt should be avoided.
If you are getting less than 7 hours a night (on average), you are getting insufficient sleep.
Trazodone is highlighted as an effective sleep aid, improving sleep architecture at lower doses. Trazodone is an anti-depressant drug approved in 1981 that has been found to be helpful for assisting with sleep. It works by improving sleep architecture and is typically used at lower doses (from 100-50mg) to avoid next-day grogginess. Ashwagandha has also been found to be beneficial for improving sleep quality. None of the other sleep drugs (Xanax, Ambien, etc.) should be taken regularly. And the dosages etc. are from what they use in their clinic to help people sleep (without e.g. Xanax!)
Tips for better sleep include:
- Avoiding alcohol, preferable altogether.
- Do not eat close to bedtime — 3 hours or more. It's better to go to bed a little hungry.
- Limiting exposure to screens and electronic devices before sleep. Aim for two hours before bed. If you must use a device, use a setting to reduce the blue light from its screen.
- Avoid doing anything anxiety-producing or stimulating — e.g. reading work emails, checking social media, etc.
- Lowering bedroom temperature (18 degrees Celsius is ideal, or mid-sixties Fahrenheit)
- Try to cool down the bed as well — there exist bed-cooling devices.
- Make your bedroom as dark as possible. It should be dark enough that you can't see your hand in front of your face with your eyes open. If this isn't possible, use an eye shade. Peter Attia uses a silky one called Alaska Bear.
- Engaging in endurance exercises during daytime with sunlight exposure.
- Establishing a fixed wake-up time.
- Do not obsess over sleep. It can actually hurt you. Turn your alarm clock away from you, so you cannot see the numbers — clock-watching makes it harder to fall asleep.
- Make sure you give yourself enough time to sleep (sleep opportunity). This means going to bed 8-9 hours before you need to wake up.
- A hot shower before bed can be good, as it’s relaxing & our core temperature drops after getting out - which helps you sleep. Sauna or hot tub is good as well.
- Exercising, particularly sustained endurance exercise, can help cultivate sleep pressure and make it easier to fall asleep. To get the best results, it is best to exercise during the day with some exposure to sunlight, as this can help keep our circadian cycle in check and ensure a good night of sleep. 30 minutes in zone 2 helps.
Evict the 21st century from your bedroom.
For those experiencing insomnia, or find themselves lying in bed unable to sleep: stop fighting it. Get up, go into another room, and find relaxing activities to do. Drink a cup of noncaffeinated tea and read a (boring) book until you feel sleepy again. What you do should be relaxing and enjoyable, but serve no function — or you'll find yourself waking up to 'be productive'. Consider that you may not suffer from insomnia, but rather that you simply are a night-owl chronotype: consider adjusting bed and wake times to align with your natural chronotype.
Sleep deprivation has been linked to poor food choices, with studies showing that people who sleep less tend to reach for unhealthy, high-calorie and sugary foods. This, combined with an increase in the hunger hormone and a decrease in the hormone that signals fullness, can lead to overeating and the development of Non-Alcoholic Fatty Liver Disease and insulin resistance.
Poor sleep has been linked to cardiovascular disease and heart attacks due to the activation of the sympathetic nervous system, which brings about an elevated heart rate and blood pressure. This places greater stress on the vasculature and can result in an increased risk of cardiac events over the long term.
Attia has used self-tracking devices to measure the effects of poor sleep, such as a higher resting heart rate and lower heart rate variability. Both of these are bad.
Mental health and maintaining healthy relationships are also emphasized, as they are as essential as regular health check-ups in contributing to overall well-being.
What's the point of living longer if your life is horrible?
Attia highlights the significance of cultivating healthy relationships with both others and oneself for overall well-being. The book argues that maintaining emotional health is equally vital as undergoing routine medical examinations and tests, even though it may be more complex to manage. Prioritizing mental health and fostering connections with loved ones is essential for a balanced life.