Book review: Outlive

Peter Attia teaches us how to live longer than the guy or gal next door

For years I tossed Peter Attia in with the Silicon Valley über-rich who consume three stem cell spinach shakes a day because they want to see what the 24th century is like. Maybe I’ll feel different when I’m eighty, but at no point in my life have I felt like living to two-hundred.

So why read this book now?

The cover is cool, and ancient wisdom teaches us that the surest way to judge a book is by its cover. But perhaps more importantly, COVID convinced me that the American healthcare system is at least halfway broken. I would trust modern medicine to,

• Give me a hip transplant

• Patch up a stab wound

• Set a broken leg

But wouldn’t trust it to,

• Treat me for a mild disease

• Prescribe a proactive treatment so I never get sick in the first place

• Be judicious in its prescription of pills with unusual side effects

As we’ll see in this review, Peter Attia expresses a similar concern about our medical system and Outlive is an excellent guide for those who would prefer to stay happy, healthy, and out of the hospital.

“I think people get old when they stop thinking about the future,” Ric told me. “If you want to find someone’s true age, listen to them. If they talk about the past and they talk about all the things that happened that they did, they’ve gotten old. If they think about their dreams, their aspirations, what they’re still looking forward to—they’re young.”
Here’s to staying young, even as we grow older.

First, here is a nutritional change I successfully implemented this summer.

I’d been going out to eat too much and decided that I should start cooking more. However, the immensity of the task overwhelmed me. I tried to imagine how I would make myself dinner every night for the next three decades, and I just couldn’t envision that reality. The task was too monumental. So I would give up and get takeout.

The revelation happened when I realized that, much like a reformed alcoholic passing on spirits, I didn’t have to think about an infinite future. All I had to do was ask myself: can I make dinner tonight?* And the answer is inevitably, yes of course. The rest of my life is an uncertainty, but I’m sure I can take care of it today.

*The inspiration for this thinking came from David Goggins. In the context of running and pushing himself forward even when he feels like his body is at its breaking point, Goggins asks himself: can I take one more step? And the answer, almost certainly, is yes. Take a big task and break it down into small parts.

Although this mindset shift comes across as childishly simple, for me it’s made all the difference. I’ve cooked more dinners in the last three weeks than I cooked in the last three months prior to that.

Cool!

Now, on to four key lessons that I learned from Outlive.

1 - How our medical system fails

Our medical system’s greatest flaw, according to Attia, is that it’s primarily designed to help patients once they’re already sick.

Medicine’s biggest failing is in attempting to treat all these conditions at the wrong end of the timescale—after they are entrenched—rather than before they take root. As a result, we ignore important warning signs and miss opportunities to intervene at a point where we still have a chance to beat back these diseases, improve health, and potentially extend lifespan.

Attia points out that while a traumatic and possibly fatal event like a heart attack appears to happen suddenly, the conditions that caused it have been building for decades. The same thing is true for diabetes, a stroke, or any number of other medical infirmities.

Unfortunately, rather than set a thirty-year-old on the right track so that they don’t have a heart attack when they’re sixty, modern medicine demands that the patient is already sick before they can be treated. Not a brilliant methodology, is it?

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.

“Come back when you’re half dead!” Is the motto of what Attia refers to as Medicine 2.0. Whereas Attia’s preventative Medicine 3.0 approach says, “You’re healthy now! That’s amazing, let’s keep it that way.”

But Medicine 2.0 does treat you once you get sick, right? Well, it tries… But apart from some crucial developments in the 20th century, we’ve not actually made much progress in extending the average person’s lifespan.

Medicine 2.0 has proved far less successful against long-term diseases such as cancer. While books like this always trumpet the fact that lifespans have nearly doubled since the late 1800s, the lion’s share of that progress may have resulted entirely from antibiotics and improved sanitation - if you subtract out deaths from the eight top infectious diseases, which were largely brought under control by the advent of antibiotics in the 1930s, overall mortality rates declined relatively little over the course of the twentieth century.

Aside from a few small exceptions (we’ve made admirable progress with leukemia), we’re not great at treating life-enders like cancer or Alzheimer’s which is why prevention is so important.

2 - Healthspan vs. lifespan

Peter Attia draws a distinction between healthspan and lifespan.

• Lifespan is how long you live, not factoring in quality of life.

• Healthspan is how many quality years of life you have.

For example, say that two people live to eighty-five…

• Debbie begins experiencing debilitating medical problems at age seventy-three. These medical damnations make the rest of her existence deeply unpleasant since she’s unable to do any of the activities that make life worth living. She had a lifespan of eighty-five and a healthspan of just seventy-three.

• Becky doesn’t begin experiencing debilitating medical problems until age eighty-three. Although she lives just as long as person Debbie, she has an extra decade of healthspan!

I hope to convince you that with enough time and effort, you can potentially extend your lifespan by a decade and your healthspan possibly by two, meaning you might hope to function like someone twenty years younger than you. But my intent here is not to tell you exactly what to do; it’s to help you learn how to think about doing these things.”

Rather than aiming for an excessively long life, Peter urges us to think about how we can extend our healthspan. By taking steps to maintain our health into old age, we will extend our lifespan as well.

3 - The centenarian decathlon

The centenarian decathlon asks what physical activities do you still want to be able to perform at eighty? Ninety? One-hundred? What can you do now that you want to continue doing for the rest of your life?

The Centenarian Decathlon is a framework I use to organize my patient’s physical aspirations for the later decades of their lives, especially their Marginal Decade. I know, it’s a somewhat morbid topic, thinking about our own physical decline. But not thinking about it won’t make it any less inevitable.

Let’s say that you want to climb four flights of stairs when you’re eighty. Back that out to the present. If you’re fifty it means you should be able to comfortably climb eight flights of stairs. If you’re thirty, you should be able to sprint up eight flights of stairs.

Are you 30? Can you sprint up 8 flights of stairs?

I just made up those requirements but that’s OK because the centenarian decathlon is two-thirds art and one-third science. Everyone ages differently and there may be no guidelines for how to extrapolate your current fitness level into what it will become when you’re older.

You may be able to get some decent guidance from a doctor or physical therapist about how much strength you’ll lose over time, but we don’t even necessarily require professional advice to start planning for our own centenarian decathlon. Each of us can think about the buffer we’ll need to build into our body to account for the irreversible loss of muscle mass and bone. You want to pick up a toddler at eighty? Well then you should probably be able to lift a seventy pound weight off the floor at forty. Can you do that?

In addition to the centenarian decathlon, Peter also introduced me to an ostensibly simple idea that actually carries a surprising amount of weight. You should contribute to your health account the same way you contribute to your retirement account. If you exercise now and keep your body in shape, that extra muscle mass, flexibility and bone strength* will return untold dividends as you age.

*Epic story about bone strength… My Uncle has skied his entire life, and is an avid hiker too. In his seventies he has a better frame than many twenty-year-olds. Well one winter he was skiing, misjudged a bit of ice and took a heroic fall. His femur was so strong that instead of shattering like a normal person’s, it punched straight through the bottom of his pelvis into his pelvic cavity. That’s a man who never skipped leg day!

4 - Exercise is crazy important

Peter Attia couldn’t be any clearer on this point: exercise is the single most decisive factor in longevity. More important than good genetics, high-tech pharmaceuticals or a perfect diet.

John Ioannidis, a Stanford scientist with a penchant for asking provocative questions, decided to test this metaphor literally, running a side-by-side comparison of exercise studies versus drug studies. He found that in numerous randomized clinical trials, exercise-based interventions performed as well as or better than multiple classes of pharmaceutical drugs at reducing mortality from coronary heart disease, prediabetes or diabetes, and stroke.

According to Peter, rucking may be one of the most effective all-around exercises to stay in shape. However, he quickly goes on to say that if loading a backpack with heavy weights and walking long distances isn’t your particular brand of vodka, that’s fine too.

The best exercise is whatever we enjoy the most, fits into our schedule and the one that we’ll stick with for the next bunch of decades.

The problem, and we will see this again in the nutrition chapters, is that we have this need to turn everything into a kind of religious war over which is the One True Church. Some experts insist that strength training is superior to cardio, while an equal number assert the opposite. The debate is as endless as it is pointless, sacrificing science on the altar of advocacy. The problem is that we are looking at these hugely important domains of life—exercise, but also nutrition, through a far too narrow lens. It’s not about which side of the gym you prefer. It’s so much more essential than that. - Poor cardiorespiratory fitness carries a greater relative risk of death than smoking.

Almost nobody should worry about exercising too much, claims Attia, but we should all worry about exercising too little.

Bits & bobs

Here’s an assortment of things, like the splatters of paint that decorated my living room in college after we got drunk and shot paintballs in the house.

Thinking may delay the onset Alzheimer’s

Using our brains to engage with complex problems, like learning a second language, may be one of the most effective methods we have of delaying the onset of Alzheimer’s. Keep reading Substacks y’all!

The more of these networks and subnetworks that we have built up over our lifetime, via education or experience, or by developing complex skills such as speaking a foreign language or playing a musical instrument, the more resistant to cognitive decline we will tend to be. - This is called “cognitive reserve,” and it has been shown to help some patients to resist the symptoms of Alzheimer’s disease.

How that’s handshake?

Grip strength is an easy and accurate proximate measure of overall strength.

A study looking at nearly half a million patients in the United Kingdom found that grip strength, an excellent proxy for overall strength, was strongly and inversely associated with the incidence of dementia. People in the lowest quartile of grip strength (i.e., the weakest) had a 72 percent higher incidence of dementia, compared to those in the top quartile.

Nutrition: good enough is good enough

Outlive provides only basic nutritional guidance. According to Peter, the same diet will affect every person differently so providing generic advice is almost impossible. Furthermore, Peter also claims that despite whatever flashy headline you’ve read about eggs, bacon, broccoli or whatever the hell else, we actually know precious little about nutrition. He goes on to claim that many of the studies “proving” that a certain food is good or bad are methodologically flawed.

Nutrition is relatively simple, actually. It boils down to a few basic rules: don’t eat too many calories, or too few; consume sufficient protein and essential fats; obtain the vitamins and minerals you need; and avoid pathogens like E. coli and toxins like mercury and lead. Beyond that, we know relatively little with complete certainty.

To expand on that quote, Peter’s nutrition advice could be summarized as the following.

• Don’t drink too much alcohol

• Eat foods from around the periphery of the grocery store

• Don’t eat anything your grandmother wouldn’t recognize

• Don’t over eat

• Don’t under eat

• Cook with olive oil

My takeaway is that when if you want to live longer your diet should be good enough. Once you’ve got your food intake halfway in order, go exercise!

Conclusions

I genuinely appreciate living in an era of antibiotics, shoulder transplants, and perhaps most of all: surgical anesthetic. Since I was a boy one of my worst fears has been a brash surgeon cutting off my leg with a hacksaw while I bite down on a leather strap so I don’t scream hard enough to blow out my vocal cords. I’m so thrilled to live in an age when that almost certainly won’t be my fate!

That being said, maybe this is a macabre but the way our medical system manages our health reminds me of this famous Monty Python skit. The cart master - a proxy for the medical system - isn’t interested unless you’re fully dead. Just like a doctor might say: you’re too healthy, come back later when it’s worse.

Thankfully the solution to this medical malarkey is easy! Read Outlive, take notes and update your lifestyle accordingly. Exercise more, get your nutrition in order and invest as much time into your health retirement account as you do your IRA.

None of us are guaranteed a long healthspan, but if we put in the work we can all give ourselves the best possible chance of being just as feisty at eighty as twenty-eight.

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