Outlive: The Science and Art of Longevity
Peter Attia MD 2023
"Another issue is that longevity itself, and healthspan in particular, doesn’t really fit into the business model of our current healthcare system. There are few insurance reimbursement codes for most of the largely preventive interventions that I believe are necessary to extend lifespan and healthspan. Health insurance companies won’t pay a doctor very much to tell a patient to change the way he eats, or to monitor his blood glucose levels in order to help prevent him from developing type 2 diabetes. Yet insurance will pay for this same patient’s (very expensive) insulin after he has been diagnosed. " Peter Attia
With all of the money that America spends on healthcare, why are we not living longer? Even worse, why are so many American's golden years plagued by disabling chronic conditions that can make their last years on earth miserable? Is there a better way for senior citizens to make themselves healthier while they live longer?
These questions have been the subject of many books, the latest and most popular of which is Dr. Peter Attia's Outlive: The Science and Art of Longevity. Dr. Attia is a Texas-based physician, author and podcast host who has written and studied extensively about the problem of aging and longevity. His podcast, called The Drive, is one of the most popular medical-related podcasts.
Dr. Attia breaks down medical practices into three general eras. Medicine 1.0 existed up through the 19th century, and was mostly based on superstition, guesswork, and many questionable treatments. Doctors back then mostly didn't understand how diseases worked, and came up with a theory of balancing "humors" with things like leeches and poking holes in the skull. Medicine 2.0 is the era that we are currently living with, and it's based on the scientific method and germ theory. We now know how many diseases are transmitted, which saves lives, and we are getting better and better at treating them with drugs and therapies.
This book preaches the importance of a new model for doctors, Medicine 3.0, which is devoted mostly to prevention, and much less to treatment. The author asks a lot of valid questions about why we focus so much on expensive tests, surgeries and treatments, and so little on the basics of preventative medicine. Once humans turn about age 60, their bodies become much more vulnerable to all sorts of problems- cognitive decline, muscle loss, depression, loss of bone density, diabetes, heart disease, communicable diseases, and cancer. These bodily changes are a natural part of the aging process, but they can be counteracted with preventative measures that delay the inevitable.
In addition, Dr. Attia distinguishes between lifespan, which is the number of years that we live, with healthspan, which is the number of years that we remain healthy enough to work, travel, drive, and pursue normal activities. While some people live long lifespans, those last years where they are sick and dependent on others for most things can be degrading and painful. As humans we need to strive for both long lives and healthy ones to maximize the quality and meaning of our short time on earth.
None of us wants to live past age 90 if that means being stuck in a nursing home unable to perform most normal human functions. To avoid that fate, the work begins much earlier, even back to age 20 or 30. Dr. Attia's practice is geared entirely towards longevity, and with that he performs a lot of tests that most doctors don't work with. (I would imagine most of his clients are wealthy enough to handle lab tests that aren't covered by insurance).
The book focuses on what the author calls the four horsemen of diseases of aging- cancer, heart disease, diabetes, and Alzheimer's or dementia. Each of those diseases can be detected earlier than they are today and countered with preventative lifestyle treatments that would lengthen and strengthen most lives. By the time they are treated and diagnosed today, it is often too late to make much of a difference.
We have heard a lot of the recommendations of this book before, but it's always good to hear it again and again, especially from the experts. The five main preventative modifications that can make the most difference are: exercise, diet and nutrition, sleep, emotion therapies, and drugs or supplements. Here are some highlights that I took away:
1- Exercise is good in so many ways. Aerobic exercise such as running, swimming or walking is great for your heart and lung strength. He recommends testing your VO2 max rate, which can be measured as a level of your breathing strength, and it is very predictive of life expectancy. Strength exercises are also critical in older age, because muscle mass normally declines, and with it our ability to balance and keep from falling. Plus muscles burn more calories and keep us from getting fatter as we age.
2- Metabolic syndrome is something that every doctor should stress from middle age onward. It predicts both heart disease and diabetes, and is a symptom of the sugar-laden standard American diet. Metabolic syndrome is indicated by the following symptoms: obesity, high blood pressure, insulin resistance, high blood triglycerides, and low HDL cholesterol. Diet and exercise can counteract this very common syndrome, but medicine today rarely addresses it until heart disease and diabetes are fully activated.
3- While heart disease is the number one cause of death, it begins at an early age with plaques and calcifications of the arteries that accumulate over time. A calcium scan can detect these problems before they do too much damage, but most blood vessel blockages aren't detected until they cause actual strokes and heart attacks.
4- Cancer screening today is mostly limited to colon, prostate, breast, and skin cancers, and even those screenings aren't always accurate or universally done. The trick to beating cancer is to catch it early. Once it metasticizes and spreads through the body, it is usually too late. Medicine needs to get much better at screening for harder to detect cancers like lung, liver, blood, mouth or brain cancer. One promising development is a "liquid biopsy" blood test that is still fairly new but is able to pick up markers of cancers inside the body.
5- Alzheimer's disease is rising rapidly as our population ages, and no reliable treatment has been found to reverse or treat it. As with other diseases, early detection can lead to lifestyle adjustments in sleep, exercise, and diet that can slow it down. Other interventions that include cognitive exercises and social interaction have been shown to improve both mood and mental ability as brains age and decline.
This book is full of both real-life advice and scientific principles that go hand in hand with staying healthy during the aging process. The author covers the five interventions in detail without being too preachy. The exercise chapters are helpful and they stress the need to keep muscle mass and breathing strength at their maximum. Without muscles, we tend to fall and give up on mobility, while without good, deep breaths, our oxygen and energy levels go down.
The nutrition chapters stress what you would expect- a Mediterranean diet high in fruits and vegetables. The book advises people to stay away from the extremes of diets- low calorie, intermittent fasting, or avoiding entire food groups. Instead he recommends experimenting with a combination of the three that incorporates the essential nutrients, especially proteins. The best diet plans are sustainable, and not gimmicky ones that only last for a month or two.
There is a chapter on sleep that is often overlooked by modern medicine. Lack of sleep is harmful to longevity, and proper sleep hygiene to get at least 7 to 8 hours per night is essential. The author closes with a personal journey of mental health, which is also often overlooked by modern medicine. The stresses of modern medicine practices today take a big toll on doctors, and the author walks through some of the challenges that he faced.
This is a valuable book for anybody over the age of 40 who wants to see age 80 or beyond. The state of American medicine is unsatisfactory for a number of reasons, and this book, (plus the author's podcast episodes) puts the knowledge and power in the hands of the patients. Unfortunately, given the poor quality of American health insurance, many of the tests and treatments that Dr. Attia recommends are beyond what most plans would cover. But still there is always something that people can work on to make themselves even a little bit healthier and more resilient for the challenges of aging. Knowledge is power.
For a challenge, here is his centenarian decathlon. If you can perform most of these tasks as you age, you are doing pretty good.
1- Go on an our and half hike
2- Get up from the floor under your own power
3- Pick up a small child from the floor
4- Carry two 5 pound bags of groceries two blocks.
5- Lift a 20 pound suitcase on a plane
6- Have sex
7- Climb four flights of stairs in three minutes
8- Balance on one leg for 30 seconds
9- Open a jar
10- Skip rope for 30 skips.