[Book 45] Outlive by Peter Attia

Outlive is about optimizing your health to minimize risks from longer term diseases. There are four primary disease categories that represent the major causes of old age mortality: 1) cardiovascular, 2) cancer, 3) neurodegenerative (e.g. Alzheimer’s), and 4) metabolic (e.g., diabetes). These conditions often develop slowly over decades, so preventative medicine is a far better remedy than treatment. Once one of these conditions meaningfully develops, it often it can only be managed, at best. Unfortunately, the medical industry operates with a treatment-first mindset, but there are signs that this is slowly changing.

Peter explains that instead of solely focusing on how long we can live, we should also be carefully planning to maximize healthspan, which considers the quality of our later years. Unsurprisingly, extensive research has found exercise to be the most potent longevity drug. What is surprising is that the type of exercise matters, and more strenuous often isn’t better. For example, regular Zone 2 cardio exercises (think a brisk walk) show significant longevity benefits and can be done in concert with other functional activities (walking the dog, commuting to work, etc.). Nutrition and sleep are two other very important variables to optimize.

This book has impact me in two key ways. Professionally, I have found that physical health has a substantial impact on the ability to consistently produce high-quality work. Second, as an actuary in the life insurance industry, being able to measure and isolate impact of preventative measures on mortality and morbidity risk is one of the most intriguing challenges we face. This book helps lay the foundation of how we might build upon the latest research.

You should read this book if you…

• seek practical advice of how to improve your longevity
• are interested in a detailed account of how long term diseases grow and manifest
• are interested in the nuance around exercise, nutrition and sleep as it pertains to longevity

Additional Information

Year Published: 2023
Book Ranking (from 1-10): 9 – Excellent – Broad and very well articulated insights
Ease of Read (from 1-5): 4 – Moderately challenging

Key Highlights

1. The odds are overwhelming that you will die as a result of one of the chronic diseases of aging that I call the Four Horsemen: heart disease, cancer, neurodegenerative disease, or type 2 diabetes and related metabolic dysfunction. To achieve longevity—to live longer and live better for longer—we must understand and confront these causes of slow death
2. Longevity has two components. The first is how long you live, your chronological lifespan, but the second and equally important part is how well you live—the quality of your years. This is called healthspan
3. 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
4. First, Medicine 3.0 places a far greater emphasis on prevention than treatment. Second, Medicine 3.0 considers the patient as a unique individual. Medicine 2.0 treats everyone as basically the same, obeying the findings of the clinical trials that underlie evidence-based medicine. The third philosophical shift has to do with our attitude toward risk. In Medicine 3.0, our starting point is the honest assessment, and acceptance, of risk—including the risk of doing nothing. The fourth and perhaps largest shift is that where Medicine 2.0 focuses largely on lifespan, and is almost entirely geared toward staving off death, Medicine 3.0 pays far more attention to maintaining healthspan, the quality of life
5. Our tactics in Medicine 3.0 fall into five broad domains: exercise, nutrition, sleep, emotional health, and exogenous molecules, meaning drugs, hormones, or supplements
6. The simplest explanation is likely that our metabolism, as it has evolved over millennia, is not equipped to cope with our ultramodern diet, which has appeared only within the last century or so
7. While it’s tricky to impossible to avoid or prevent the genetic mutations that help give rise to cancer, it is relatively easy to address the metabolic factors that feed it. I’m not suggesting that it’s possible to “starve” cancer or that any particular diet will magically make cancer go away; cancer cells always seem to be able to obtain the energy supply they need. What I am saying is that we don’t want to be anywhere on that spectrum of insulin resistance to type 2 diabetes, where our cancer risk is clearly elevated. To me, this is the low-hanging fruit of cancer prevention, right up there with quitting smoking. Getting our metabolic health in order is essential to our anticancer strategy
8. I’m not quite as confident that regular sauna use will reduce your risk of Alzheimer’s disease as I am that exercise will do so, but I am much more confident than I was at the outset of my journey. The best interpretation I can draw from the literature suggests that at least four sessions per week, of at least twenty minutes per session, at 179 degrees Fahrenheit (82 degrees Celsius) or hotter seems to be the sweet spot to reduce the risk of Alzheimer’s by about 65 percent (and the risk of ASCVD by 50 percent)
9. Our two most complex tactical domains are nutrition and exercise, and I find that most people need to make changes in both—rarely just one or the other. When I evaluate new patients, I’m always asking three key questions: a. Are they overnourished or undernourished? That is, are they taking in too many or too few calories? b. Are they undermuscled or adequately muscled? c. Are they metabolically healthy or not?
10. Study after study has found that regular exercisers live as much as a decade longer than sedentary people. Not only do habitual runners and cyclists tend to live longer, but they stay in better health, with less morbidity from causes related to metabolic dysfunction
11. On it goes. To lift that twenty-pound suitcase overhead when you are older means doing so with forty or fifty pounds now. To be able to climb four flights of stairs in your eighties means you should be able to pretty much sprint up those same stairs today. In every case, you need to be doing much more now, to armor yourself against the natural and precipitous decline in strength and aerobic capacity that you will undergo as you age
12. The key is to find an activity that fits into your lifestyle, that you enjoy doing, and that enables you to work at a steady pace that meets the zone 2 test: You’re able to talk in full sentences, but just barely
13. The payoff is that increasing your VO2 max makes you functionally younger. One study found that boosting elderly subjects’ VO2 max by 6 ml/kg/min, or about 25 percent, was equivalent to subtracting twelve years from their age
14. I think of strength training as a form of retirement saving. Just as we want to retire with enough money saved up to sustain us for the rest of our lives, we want to reach older age with enough of a “reserve” of muscle (and bone density) to protect us from injury and allow us to continue to pursue the activities that we enjoy. It is much better to save and invest and plan ahead, letting your wealth build gradually over decades, than to scramble to try to scrape together an individual retirement account in your late fifties and hope and pray that the stock market gods help you out. Like investing, strength training is also cumulative, its benefits compounding. The more of a reserve you build up, early on, the better off you will be over the long term
15. The correlation between poor metabolic health and being overnourished and undermuscled is very high. Hence, for a majority of patients the goal is to reduce energy intake while adding lean mass. This means we need to find ways to get them to consume fewer calories while also increasing their protein intake, and to pair this with proper exercise. This is the most common problem we are trying to solve around nutrition
16. The Standard American Diet (SAD) on one level, is brilliant, a solution to four problems that have plagued humanity since the beginning: (1) how to produce enough food to feed almost everyone; (2) how to do so inexpensively; (3) how to preserve that food so it can be stored and transported safely; and (4) how to make it highly palatable. If you optimize for all four of these characteristics, you’re pretty much guaranteed to end up with the SAD, which is not so much a diet as a business model for how to feed the world efficiently. But notice that a fifth criterion is missing: how to make it harmless
17. The first thing you need to know about protein is that the standard recommendations for daily consumption are a joke. Right now the US recommended dietary allowance (RDA) for protein is 0.8 g/kg of body weight. This may reflect how much protein we need to stay alive, but it is a far cry from what we need to thrive. There is ample evidence showing that we require more than this—and that consuming less leads to worse outcomes. More than one study has found that elderly people consuming that RDA of protein (0.8 g/kg/day) end up losing muscle mass, even in as short a period as two weeks. It’s simply not enough
18. In the final analysis, I tell my patients that on the basis of the least bad, least ambiguous data available, MUFAs are probably the fat that should make up most of our dietary fat mix, which means extra virgin olive oil and high-MUFA vegetable oils. After that, it’s kind of a toss-up, and the actual ratio of SFA and PUFA probably comes down to individual factors such as lipid response and measured inflammation. Finally, unless they are eating a lot of fatty fish, filling their coffers with marine omega-3 PUFA, they almost always need to take EPA and DHA supplements in capsule or oil form
19. Good sleep is like a performance-enhancing drug