Outlive: The Science and Art of Longevity, by Dr. Peter Attia

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I’ve had several friends recommend Attia’s book to me over the past year as a way to live a longer and more healthy life, so I recently read it as part of my 50th birthday activities.

Attia’s main premise is that current medical practices are about delaying death, figuring out how to keep somebody alive after they have been diagnosed with a disease. Attia proposes that we instead focus on preventing the disease; rather than extending life for a few miserable years after somebody is already suffering from what he calls the “Four Horsemen” of heart disease, cancer, neurogenerative disease or type 2 diabetes, let’s see what we can do to extend the healthy years (aka “healthspan”) before those diseases take over.

This shift involves a few changes in philosophy. Rather than recommend practices that will work for everybody on average, Attia thinks we need to treat each person as a unique individual with their own set of risk factors including genetic propensities. This also means that he treats risk differently – rather than default to doing nothing, he works with his patients to assess the risk of various options and may recommend something that would be slightly risky for an average person but may be quite beneficial to this particular patient. But the main difference is that he uses this book to share a framework for thinking about healthspan; rather than making specific recommendations, he wants each person to design a different action plan based on their situation.

The key components for extending healthspan are unsurprising: exercise, diet, sleep and emotional health.

For a long and healthy life, it makes sense that we need strength, bone density and aerobic fitness. But Attia’s insight that most struck me was that once we pass 50 years old, it gets much harder to build muscle and bone density; on average, humans lose 10-20% of muscle per decade as they get older. So if I want to be lifting 30 pounds over my head when I’m 80 (e.g. to lift a grandchild), I need to be lifting 50 pounds when I’m 50. Attia also observes that it requires more effort to maintain muscle mass as you get older; in my 20s, most of my effort in exercise would go to growing muscle mass, but in my 50s, most of that effort is being used to fight the decline of muscle. Exercise is also critical because being strong and stable prevents injury due to accidents and falls as we age.

The takeaway for me is to commit to exercising in ways that build muscle and bone density. I joined a gym called Functional Lifestyles that is aligned with that goal, and they have been great in prompting me to do exercises I wouldn’t normally do. Pull-ups and chin-ups are important as they help develop grip strength, which Attia recommends as “almost all actions begin with the grip”. Core exercises are critical for increasing stability; as Attia writes, developing stability connects “our body’s different muscle groups with much less risk of injury to our joints, our soft tissue, and especially our vulnerable spine.” I started “rucking”, which is walking with extra weight in a backpack, which means that my afternoon walks now build a little strength and bone density in addition to cardiovascular fitness. We will see how long I stay committed to these new practices but with young kids, it is important to me to invest in my long-term strength so I can stay active and keep up with them as I age.

Nutrition is also relatively straightforward; as Attia summarizes, “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 or lead.” The main goal is to avoid “metabolic dysfunction”, of which the endpoint is type 2 diabetes, but which Attia believes we can address long before we reach the point of our pancreas breaking (or our liver suffering from cirrhosis). The metabolic dysfunction criteria are high blood pressure, high triglycerides, low HDL cholesterol, elevated fasting glucose and “central adiposity” (large waistline). This often happens when we overload our system with what Attia calls the standard american diet – too many calories, too many carbohydrates, too much sugar. Instead, he recommends eating more protein (to build muscle), fat (as an alternate direct fuel source rather than carbohydrates getting turned into fat) and vegetables (to get the necessary vitamins and minerals), while extolling the benefits of calorie restriction – eating less calories is correlated with longer healthier lifespan.

My main takeaway from this section was to reduce carbohydrates in my diet and eat more protein (he recommends as much as 1 gram per pound of body mass, which for me would be 200+ grams of protein a day or 4 servings of meat a day! I’m not going to get there but aim to raise my protein intake). I also started supplementing my diet as suggested by a podcast interview I heard with Dr. Rhonda Patrick, who recommended fish-oil pills for omega-3, vitamin D supplements (because none of us get enough sun any more), and smoothies made with kale (for folate) and blueberry (for antioxidants) and protein powder. If nothing else, these changes reduce the glucose spikes after meals which leads to a smoother metabolic day; Attia suggests continuous glucose monitoring as a recommended practice to learn to manage your diet to avoid such spikes. But he also says “In the end, the best nutrition plan is the one that we can sustain. How you manipulate the three levers of diet — calorie restriction, dietary restriction, and time restriction — is up to you. Ideally, your plan improves or maintains all the parameters we care about — not only blood glucose and insulin but also muscle mass and lipid levels”.

On sleep, Attia says “poor sleep wreaks havoc on our metabolism. Even in the short term, sleep deprivation can cause profound insulin resistance.” and “sleep and cognitive health are deeply intertwined; this is why one of the pillars of Alzheimer’s disease prevention, particularly for our high-risk patients, is improving their sleep.” The prescription for sleep is pretty straightforward: “a good night of sleep may depend in part on a good day of wakefulness: one that includes exercise, some outdoor time, sensible eating (no late-night snacking), minimal to no alcohol, proper management of stress, and knowing where to set boundaries around work and other life stressors” while also sleeping in a dark cold (65 degrees Fahrenheit) room without devices.

I do most of those things each day e.g. I had already noticed how alcohol messes with my sleep so I’ve been drinking less and rarely doing a nightcap right before sleep. But that hasn’t been enough, so I got myself tested for sleep apnea because I “snore, have high blood pressure, [and] feel tired most days”. I tested slightly positive and will experiment with a CPAP device to see if my sleep improves as a result (it would also help if my 3-year-old didn’t wake me up a couple times a night).

Lastly, emotional health. As Attia’s therapist, the famous Esther Perel, asked him, “Isn’t it ironic that your entire professional life is predicated around trying to make people live longer, yet you’re putting no energy into being less miserable, into suffering less emotionally? Why would you want to live longer if you’re so unhappy?” I already have done a lot of work on myself in this area through therapy and coaching, but recommend the chapter for those that struggle with emotional resilience. To increase one’s ability to tolerate distress, Attia recommends “exercise, sound sleep, good nutrition, time with my family, deep social connections, spending time in nature, and recreational activities that do not emphasize self-judgment”, because those are the things you control. When something goes wrong, rather than blame the situation or the other person, do one of those activities to help you reset yourself (I’d add meditation and journaling to that list as activities that are useful for me).

I was a bit disappointed in this book, as it was 400 pages long with limited insights as I had heard most of these recommendations before. I don’t think you need to read the book if you just want to implement the changes I shared above, unless you’re curious about the underlying science (part 2 explaining the biochemical reasoning behind these recommendations was a slog for me) or want to read how Attia works with his patients to increase their healthspan. While he draws on medical studies, including what separates those who healthily live past 100 years old from the rest of us, his work is a bit speculative as it’s too early and too complex to say what will work – we won’t see the results of these recommendations for decades. But I was convinced to change a few things as a result of reading this book and I think they will likely be good for me. If nothing else, I enjoy being stronger and more active, and the diet changes make me feel more energetic, so hopefully I can get these changes to stick.

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