Book Report: Outlive Author: Peter Attia
Publication: 2023
Pages: 411
Why I read this book: Human longevity is a passion of mine. I truly believe that if I take the correction actions now, I can probably live 10-15 years longer than other people my age- and be much healthier than others of my age at that time healthy enough to truly enjoy life.
What I learned from this book:
1) There are 4 chronic diseases of aging called the 4 Horsemen: Heart Disease, Cancer, Neurodegenerative Disease or Type 2 diabetes & related metabolic dysfunction.
2) Longevity has two components – How long you live (your chronological lifespan) and the second & equally important is how well you live – the quality of your years.
3) Your goal should be to act as early as possible to identify issues and address them. We want to delay or prevent conditions so that we live longer without disease, rather than lingering with disease. We should be proactive instead of reactive.
4) A typical cholesterol panel from your annual physical, along with the underlying assumptions behind it (e.g. “good” & “bad” cholesterol), is misleading & oversimplified to the point of uselessness.
5) The metabolic derangement that leads to type 2 diabetes (T2D) also helps foster & promote health disease, cancer and Alzheimer’s disease (AZ). Addressing our metabolic health can lower the risk of each of the Horsemen.
6) Protein is the most important macronutrient we need to focus on.
7) Exercise is, by far, the most potent longevity “drug,” followed by high quality/quantity of sleep. Most people don’t do nearly enough of the correct types of exercise or get good sleep.
8) Striving for physical health & longevity is meaningless if we ignore emotional health.
9) It is better to pro-actively focus on preventative medicine than the treatment of an existing disease.
More important details:
1) The five stages of grief are: 1) Denial, 2) Anger, 3) Bargaining, 4) Sadness & 5) Acceptance.
2) The Four Horsemen are highly correlated and the diseases should not be treated as being separate from one another. We should be looking for their commonalities. This association is driven by inflammation and insulin resistance.
3) Medicine 3.0 is not to patch people up and get them out the door, removing their tumors and hoping for the best, but rather to prevent the tumors from appearing & spreading in the first place.
4) Medicine 3.0 places a far greater emphasis on prevention than treatment. It considers the patient as a unique individual. The starting point is the honest assessment, and acceptance, of risk – including the risk of doing nothing.
5) Healthspan & its deterioration have three vectors: 1) cognitive decline, 2) decline & eventual loss of function of our physical body and 3) emotional health.
6) Medicine 3.0 falls into five broad domains in order of importance: a) exercise, b) nutrition, c) sleep, d) emotional health and e) exogenous molecules such as drugs/hormones/supplements.
7) Exercise is the most potent longevity “drug” in the arsenal in terms of lifespan and healthspan. It not only delays death, but also prevents both cognitive and physical decline, better than any other intervention. The most important components of exercise are a) strength, b) stability, aerobic efficiency and d) peak aerobic capacity.
8) There are specific genes that affect longevity.
a. One of the most potent individual genes yet discovered is related to cholesterol metabolism, glucose metabolism and AZ disease risk. This gene is called APOE and it has three variants: e2, e3 & e4. E3 is the most common but having one or two copies of e4 variant seems to multiply one’s risk of developing AZ disease by a factor of between 2 and 12.
b. The e2 variant seems to protect its carriers against dementia & turns out to be very highly associated with longevity.
c. There are two other cholesterol-related genes are CETP & APOC3 correlated with extreme longevity. These two genes may explain why centenarians rarely die of heart disease.
d. FOXO3 gene activates other genes to keep us healthy while preventing cancer. It is activated by exercise & slight nutrient deprivation.
9) The goal is to stop diseases before they start. We must focus on delaying the onset rather than extending the duration of the disease – and not just one disease but all chronic disease. Our goal is to live longer without disease.
10) There are some common drugs that should be looked at in terms of longevity: a) rapamycin, b) resveratrol, c) metformin
a. Rapamycin – it is commonly given to transplant patients. It slows down cellular growth & division, is found in all forms of life & reduces inflammation, which allows for improved cancer detection and elimination by the body. When given in your 60’s, it increases life span by 28%. The best approach is low to medium doses followed by a rest period.
b. Resveratrol – is found in the skins of red grapes. The success of this has not been replicated. Still, it can be obtained from a grapeseed extract.
c. Metformin – those taking metformin for long periods of time appear to have a lower incidence of cancer than the general population. One study showed that diabetics on metformin actually lived longer than non-diabetics not takin metformin.
11) Limiting caloric intake can lengthen lifespan by 15-45% and you will be healthier for your age, developing fewer tumors, making you less likely to die from cancer. The less you eat, the longer you will live. This must be done within reason because if you are too skinny, you may be more prone to death from infection or cold temperatures.
12) Subcutaneous fat is the safest place to store excess energy as it plays an important role in maintaining metabolic health. Once that reaches capacity, it starts getting stored in your blood as triglycerides, liver contributing to fatty acid liver disease and in your muscle tissue which leads to insulin resistance.
13) Those with diabetes have more cardiovascular diseases, cancer & AZ.
14) The current body is not conditioned to consume our current carbohydrate & sugar-rich diets. It has not evolved over time to take in this much energy, especially given our sedentary lifestyle.
15) Half of all heart attacks for men and 1/3 of all heart attacks for women occur before the age of 65.
16) Cardiovascular risk is difficult to determine. The best way to do it is with a CT angiogram which identifies soft plaque better than a standard angiogram.
17) The apoB test is far more predictive of CV disease than simply LDL-C, the standard “bad cholesterol” measure. It is a cheap test as well – less than $50.
18) The association between obesity, diabetes and cancer is primarily driven by inflammation & growth factors such as insulin. Obesity from visceral fat promotes inflammation, creating an environment that can induce cells to become cancerous. It also leads to the development of insulin resistance. A simple way to help with this is avoid refined sugars & carbohydrates like white bread, white rice, pasta and potatoes.
19) Fasting makes normal cells more resistant to chemo and cancer cells more vulnerable to the treatment – basically turbocharging chemotherapy.
20) The top five deadliest cancers (in order) are: a) lung, b) breast/prostate for women/men, c) colon, d) 1 pancreas and e) liver. Because cancer is hard to prevent, it is important to detect it as early as possible.
21) Regarding AZ, one hypothesis is that giving drugs that target amyloid-beta in brains should be given early, before AZ takes hold of people predisposed to AZ. This will yield better results.
22) Interventions around nutrition, physical activity and cognitive training helped maintain cognitive function and prevent cognitive decline.
23) Restoring blood flow to the brain is key to brain health. AZ may be a vascular disorder of the brain.
24) AZ is twice as common in women vs. men. There may be something about menopause and the abrupt decline in hormonal signaling that sharply increases neurodegeneration in women.
25) Men are twice as likely to suffer from Lewy body dementia and Parkinson’s disease. Exercise is the only intervention that delays the onset of Parkinson’s. The more complex the movement – the better. For instance, dancing is better than walking.
26) Your sense of smell is one of the first things to be affected by AZ.
27) There are a list of factors that help prevent AZ:
a. Exercise It helps maintain glucose homeostasis and the health of our arteries/veins.
b. Sleep-This is when our brain heals itself. While in deep sleep, are brains are sweeping away intracellular waste that can build up between neurons.
c. Diet Mediterranean, keto or carnivore or combination thereof.
d. A surprising risk factor for AZ is hearing loss. It seems hearing loss may be causally linked to cognitive decline because people pull away & withdraw from interactions with others. When the brain is deprived of inputs, it withers.
e. Brushing & flossing teeth reduces inflammation, which helps reduce AZ.
f. Dry saunas – Four sessions per week, 20 minutes per session at 82 C is optimal.
g. Vitamins Vitamins D, C & Zinc are good for AZ prevention and general health.
h. Hormone therapy for women during transition from perimenopause to menopause seems promising.
Exercise – the most powerful longevity “drug.”
1) Regular exercisers live ten years longer than sedentary people. Not only do they live longer, but they stay in better health with less morbidity. The benefits of exercise begin with any amount of activity north of zero – even brisk walking. Thirty minutes of moderate intensity aerobic activity five times per week is enough to see a good impact.
2) Peak aerobic cardiorespiratory fitness, measure in VO2 max, is perhaps the single most powerful marker for longevity. VO2 max represents the maximum rate at which a person can utilize oxygen. This is measured while a person is exercising at their upper limit of effort. The higher the VO2, the lower the mortality.
3) The best exercise is aerobic + strength + stability. Aerobic means running, cycling, swimming or something similar. Rucking with a backpack adds an element of strength to the aerobic equation.
4) Strength training is based around the following exercises:
a. Grip strength, how hard you can grip with your hands, involves everything from your hands to your lats. Almost all actions begin with the grip. Strong grip strength is correlated to decreased mortality.
b. Attention to concentric & 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.” A great example is focusing on the “down” phase of lifts ranging from pull-ups, pull-downs, or rucking downhill with a weighted pack.
c. Pulling motions, at all angles from overhead to in front of you, which also requires grip strength (pull-ups & rows). A rowing machine is another simple & effective way to work on pulling strength.
d. Hip-hinging movements, such as the deadlift & squat, but also step-ups, hip-thrusters, and countless single-leg variants of exercises that strengthen the legs, glutes, and lower back. You bend at the hips, not the spine, to harness your body’s largest muscles, the gluteus maximus and the hamstrings. It is a very powerful move that is essential to life. There is simply too much to compress this into a book report on this topic. To learn more about this, you can find this information in the book on pages 285-287.
5) It is best to exercise in Zone 2, which means going at a speed slow enough that one can maintain a conversation, but fast enough that the conversation is strained.
6) Stability is often conflated with “core,” but there is much more to it than that. Stability is essential to any kind of movement, particularly if our goal is to be able to keep doing that movement for years or decades. It is the foundation on which the two twin pillars of cardiovascular fitness & strength must rest. A technical definition is the subconscious ability to harness, decelerate or stop force.
7) Stability begins with proper breathing. Deep steady breathing activates the calming parasympathetic nervous system, while rapid or ragged breathing triggers its opposite, the sympathetic nervous system, part of the fight-or-flight response. Breathing is important to stability & movement, and even to strength.
8) A major focus of stability is the spine.
9) The portion of the book that discusses stability is highly technical and difficult to condense down. To learn more, reach Chapter 13 of the book.
Nutrition 3.0
1) Instead of a diet, we are talking about nutritional biochemistry. That takes it out of the realm of ideology, religion & emotion and puts it back into the realm of science. Nutrition 3.0 is scientifically rigorous, highly personalized & driven by feedback and data rather than ideology & labels.
2) What problems are we trying to solve? What is our goal with Nutrition 3.0? It boils down to the following three questions:
a. Are you undernourished or over-nourished?
b. Are you under-muscled or adequately muscled?
c. Are you metabolically healthy or not?
3) In nearly all cases, the American diet requires additional meat protein.
4) Here are a few basic nutritional rules:
a. Don’t eat too many calories, or take too few.
b. Consume sufficient protein & essential fats.
c. Obtain the vitamins & minerals you need.
d. Avoid pathogens, toxins & heavy metals.
5) There is a clear advantage in the Mediterranean diet, olive oil & nuts.
6) All diets rely on at least one of the following three strategies to eat less and better:
a. Caloric Restriction (CR) – eating less in total, but without attention to what is being eaten or when it’s being eaten.
i. If we take in more energy than we require, the surplus ends up as fat, one way or the other.
ii. Excess calories contribute to metabolic diseases, heart disease, cancer & AZ.
iii. Eating fewer calories tends to lengthen lifespan.
b. Dietary Restriction (DR) – eating less of some particular element with the diet.
i. Alcohol is calorie dense and the oxidation of alcohol delays fat oxidation, the opposite of what we want. It may also lead to needless eating. You should have a maximum of 7 servings per week.
ii. Carbohydrates are our primary source of energy and are broken down in to glucose. 1. Use Continuous Glucose Monitoring (CGM) as it gives real-time information on blood glucose levels so the patient can see how their levels are responding to whatever they eat & it keeps track of this data over time. It is a very individualized approach that gives an indication of a patient’s insulin response. It is more accurate than HbA1c testing. After 2 months of use, you will understand what foods are spiking your glucose and how to adjust your eating pattern to obtain a more stable glucose curve (Pages 328-330).
iii. Protein & amino acids are the building blocks of life. The USDS RDA is too low. In order to gain or maintain muscle mass, you should eat 1.6 grams of meat protein/kg bodyweight/day.
iv. Fats the balance of our diet is fats. Eat more olive oil, avocados & nuts & eat less corn, soy, & sunflower oils. It is good to take capsules of Omega-3 oils (DHA & EPA) as a supplement.
c. Time Restriction (TR) – restricting eating to certain times, up to and including multiday fasting.
i. Some good things happen with intermittent fasting (IF). Insulin drops dramatically because there are no incoming calories, the liver is emptied of fat relatively quickly, autophagy (cellular recycling process) is accelerated and FOXO (the cellular repair gene) is activated.
1. The 18/6 (18 hours of fasting & 6 hours of eating or 20/4 is needed to eke out enough of a calorie deficit for IF to be effective.
2. IF leads to protein deficiency. If you want to gain lean muscle mass, you will have to avoid IF or consume a pure protein source when eating.
3. IF may be the best approach to people with very high Body Mass Indexes get their weight down quickly.
d. Miscellaneous i. It is best to never drink sodas, fruit drinks or sports drinks laden with sugar. ii. Protein is the most important macronutrient and should not be skimped on.
Sleep – The Great Awakening
1) Sleep, diet and long-term diseases are all intertwined with good sleep.
2) One sleepless night can create a state that is the functional equivalent of being legally drunk.
3) There are powerful associations between insufficient sleep & adverse health outcomes from increased susceptibility to colds to dying of a heart attack.
4) Sleep may be more important for the brain than the body. Good sleep, in terms of quantity & quality, is critical to our cognitive function, our memory & our emotional equilibrium. It is essential to preserving our cognition as we age & stave off AZ. Athletes who sleep poorly the night before a race or match perform markedly worse than when they are well rested. Endurance drops, VO2 max drops, one-rep-max strength drops and potential for injuries increases.
5) Consistent lack of sleep can lead to “Old Man Blood,” meaning that blood tests will reveal high insulin & triglycerides and low testosterone. There are risk associations between lack of sleep and hypertension, cardiovascular diseases, coronary heart diseases and obesity. It can lead to higher stress, prompting the release of cortisol & increasing blood pressure while inhibiting the uptake and utilization of glucose in the muscle & fat tissues.
6) Poor sleep changes the way we behave around food. Limiting sleep to 4-5 hours a night suppresses leptin, the hormone that signals to us that we are fed; while increasing levels of ghrelin, the “hunger” hormone. You are more likely to seek out high-calorie & sugary foods or indulge in a fourth meal at the end of the evening if you do not get enough sleep.
7) Poor sleeping habits lead to increased CV disease & not getting enough sleep harms the brain.
8) How to get the best sleep:
a. Don’t drink alcohol. If you do, just have one drink before 6 pm.
b. Don’t drink caffeine after 2 pm – earlier if you have more than one cup/day.
c. Always finish eating at least 3 hours before bedtime.
d. Abstain from electronics (tablets, phones, etc) at least two hours before bed.
e. Avoid doing anything anxiety producing or stimulating at least one hour before bed.
f. If you have access, spend time in a sauna prior to bed.
g. The room should be cool (mid-60’s Fahrenheit).
h. Darken the room completely. Cover any LED lights on TV’s, DVR’s, etc.
i. Go to bed 8-9 hours before you are getting up. This gives you adequate time to fall asleep. Fix your wake up time so that you wake up the same time every day, including the weekends. j. Do 1⁄2 hour of Zone 2 exercise 1⁄2 hour before bed.
k. Trazadone (100 mg) may also be a good sleep drug. Dr. Parsley’s sleep medicine is also good.
l. Always shoot for 8 hours of uninterrupted sleep.
Emotional Health- A High Price to Ignore It
1) Emotional health requires proper nutrition, exercise and appropriate sleep to be well regulated.
2) Mindfulness & meditation – find time to calm down and decompress.
3) Deep breathing exercises-activates the calming parasympathetic nervous system.
4) Anti-depressants & mood stabilizers.
5) Spend time with family/friends and/or in nature.
6) Dialectical behavior therapy (DBT) teaches new ways of thinking about or acting on their problems. You learn to execute concrete skills, repetitively, under stress, that aims to break the chain of negative stimulus → negative emotion → negative thought
7) The four pillars of DBT are:
a. Emotional regulation – getting control over our emotions.
b. Distress tolerance – our ability to handle emotional stressors. negative action.
c. Interpersonal effectiveness – how well we make our needs & feelings known to others.
d. Self-management – taking care of ourselves, beginning with basic tasks like going to work.
