A Summary of Key Ideas from Outlive: The Science & Art of Longevity by Peter Attia, MD

In past posts, I’ve mentioned Peter Attia, MD. And I’ll state it again that I am so glad that I finally tuned into his podcast The Drive about 6 months ago. Despite being a guest on several podcasts myself, I actually never listen to them…. until one of my inner circle friends kept urging me to give this one a listen. He knows me well - curious, evidence-based and interested in the science and art of health, fitness, functional capacity and wellness …. so Peter Attia and The Drive was an excellent choice.

In late March, Attia published his first book -  Outlive: The Science & Art of Longevity which largely reflects the podcast. Both the podcast and the book can get fairly technical. I’ve had graduate coursework in biochemistry, human physiology, epidemiology, etc. and still find myself re-winding or re-reading … and still this sometimes is not enough as I need to search other elementary sources to try to learn and figure things out. Nonetheless, in my opinion, Attia along with Bill Gifford, do an excellent job of storytelling and translating research, science and medicine. If you are scientifically literate and/or curious and growth mindset, and interested in the science and art of living well, this is a good read.

For those who either do not like to read, are intimidated by the technical aspects of the topic, or merely time-starved, here is an overview and summary of key nuggets of the book along with some personal points as well.

---

---

Books tell a story - from cover to cover - chapter 1 to the final sentence. As Seinfeld’s George Costanza once declared “I’m going to a read a book - from start to finish - and in that order.” Well, sometimes I have a bit different sequence than the author had in mind. In this book, I start with the Intro chapters and then cover the chapters on Centenarians and Heart Disease (1 of the Four Horsemen) before grouping the chapters on Nutrition and Exercise, and then finally covering Sleep and Emotional Health. 

---

Chapters 1-3. Introduction to The Science and Art of Longevity

When I think about lifespan, I start with the end in mind. What’s my expiration date? And how do I get there via quality years of life. How do I play the long game? As Attia likes to say - healthspan instead of lifespan.

Many chronic diseases like type 2 diabetes, atherosclerotic cardiovascular disease, cancer, and Alzheimer’s Disease (which Attia refers to as the ‘Four Horsemen’) are quite prevalent in contemporary societies. One important point that Attia makes is that they should not be thought of as ‘binary’ like a cold (you have it or you don’t). Instead, they operate along a continuum. Indeed, there are several more people on the brink of diagnosis - a clinical cutpoint like a line in the sand - and in today's unhealthy society, being on this side of the line - normal or average - is not necessarily the same as optimal. And herein lies the issue with modern medicine and even “preventive” medicine. Instead, we should be seeking proactive medicine, or what Attia has termed ‘Medicine 3.0’. In Medicine 3.0, the major tenets are:

• Prevention > Treatment

• Individualize your health and lifestyle plan and actions

• Routinely assess your risk - know your numbers

• Think healthspan and Quality of Life (QoL)

Longevity thinking also needs to start early - like in your twenties, if not sooner. As a fifty-three year old, I feel the downward slope of biological function! So, what's your plan for bending the healthspan curve for cognitive & physical function and emotional health? What are your Objectives, Strategies, and Tactics? A hint: do the key lifestyle factors brutally well and consistently.

In terms of the science, unfortunately there are no long-term RCTs (randomized clinical trials) incorporating all of the key lifestyle factors that examine the prevention of chronic disease/expanding healthspan. Instead, we need to rely on studies of centenarians, animal models, human studies of risk factors, mechanistic studies of disease, etc.

So, how can we have absolute certainty? Attia writes "living systems are messy and confounding and complex ... the best we can hope for is reducing our uncertainty .. and think in terms of probabilities and risk."

“living systems are messy and confounding and complex ... the best we can hope for is reducing our uncertainty .. and think in terms of probabilities and risk”

Chapter 4. What can we learn from Centenarians?

100 years. 36,500 days. A modern-day centenarian would have been born in 1923. It’s the Roaring Twenties and Prohibition is in order. Yankee Stadium opens and Babe Ruth wins his first MVP award. This person will graduate high school amidst World War II.

It may take a while to find a centenarian. In the United States, about .03% or 1 in 3,333 persons is 100 years old.

What makes a centenarian? Is it in the genes? a healthy lifestyle? Several researchers are engaged with this question including The New England Centenarians Study, the largest and most comprehensive study of centenarians and their families in the world!

There are a few candidate genes for longevity, but no perfect centenarian genome. In terms of lifestyle, well… some drink excessively, smoke, eat poorly …. but it appears the key is resiliency.

Chapter 7. Heart Disease, the deadliest killer on the Planet

The statistics for heart disease morbidity and mortality are alarming. Here’s one - in the United States, someone has a heart attack every 40 seconds - and a link to the 2022 Heart Disease & Stroke Statistical Update Fact Sheet Global Burden of Disease for those who want to explore more.

The most common notice that you have heart disease? Unfortunately, sudden death. Think about it - death.

This is why knowing your numbers is soooooo important.

• First and foremost, know your family history, especially early onset of heart disease (<55 yrs men; <45 yrs women), and consider genotyping for key candidate genes (23&Me)

• Don’t smoke (period. No … exclamation point! Don’t smoke!!). And if you do, get help to quit smoking.

• Go beyond the standard lipid profile of total cholesterol, HDL (“good” cholesterol), LDL (“bad” cholesterol) and Triglycerides. Specifically, request apoB & Lp(a) - you will likely pay out of pocket but it’s worth it in understanding your risk.

• Get a handle on glucose metabolism probably going beyond fasting glucose; what is your A1C (90-day glucose), how does your body respond to eating/exercise/stress? Get an oral glucose tolerance test or try continuous glucose monitoring (CGM) if possible.

• Take a look inside the artery; get a Coronary Artery Calcium (CAC) score or heart scan

• Measure Blood Pressure routinely (and consider morning Heart Rate Variability, HRV)

• Think beyond the standard 10-year risk score; think 30 years out instead

• What’s your Vo2max or maximal aerobic fitness level?

• Are you getting enough exercise? sleep? Eating a healthy diet? Managing stress and emotional health?

Chapter 10. A Framework for Longevity/Health

The human genome of our ancestral hunter-gatherer was not intended for our contemporary toxic built environment where our genes no longer match the environment. Therefore, we must be cunning with our tactics to adapt & thrive in this new & hazardous environment.

Patient’s in Attia’s medical practice are evaluated for the following (alongside the above):

• +/- nourished (calories) via DXA scan total and regional/abdominal body fat

• +/- muscle mass via DXA scan

• +/- metabolic health via glucose/lipids and Vo2max

Of course, the goal is to live longer and better. To create healthspan.

What’s the approach? The approach, of course, includes optimizing lifestyle behaviours (nutrition, sleep, exercise, stress management) via:

• There is no blanket or one-size-fits-all solution; it is not prescriptive

• Give the person some direction to create their own playbook (teach them how to fish)

• Empower them

• Take Action: it's not easy to change habits

• Allow for some tinkering & experimentation, so that optimal, individualized solutions can get dialed in

Chapters 5-6, 14-15. Nutritional Biochemistry

First off, Attia dislikes the term diet and prefers the term ‘nutritional biochemistry’, which explains the complex, intertwined processes of nutrients and metabolism.

Given the rate of obesity or overfatness in many Americans and others around the World, caloric overload is an important issue. Obesity, and specifically central or truncal obesity, is linked to high blood pressure, cholesterol, and glucose and what is called the Metabolic Syndrome. However, it’s just not obese individuals that have health issues as 22% of non-obese people meet criteria for the Metabolic Syndrome. Think about that - outward bodily appearance or physique is not everything! They are the “skinny” metabolically unhealthy. They also likely suffer from low muscle mass.

Attia writes “…the logical first step in our quest to delay death is to get our metabolic house in order.” A major culprit is fructose, especially sugar-sweetened beverages. Consumption of fructose leads to dysfunctional metabolism via abnormal insulin response to feeding which leads to insulin resistance and fatty liver and ultimately elevated glucose levels and the diagnosis of type 2 diabetes, which in turn increases the risk of CVD (6x), cancer (12x), and Alzheimer’s disease (5x). Metabolism matters!

“…the logical first step in our quest to delay death is to get our metabolic house in order.”

The keys to nutrition are:

• what you eat (dietary composition)

• when you eat (timing)

• how much you eat (calories)

or what Attia refers to as the three levers

• Dietary Restriction (find best mix of macronutrients)

• Time Restriction

• Caloric Restriction

Nutrition 3.0 is based on data and feedback instead of labels, trends, and dogmatic ideology. Attia stresses that in general, diet and nutrition are poorly understood by science .. and definitely muddled by misinformation. He advises to “think instead of figuring out what works for your body (your nutritional biochemistry) and goals and what you can stick with.”

Bad nutrition can hurt us more than good nutrition can help us.

Pro Tip: Shop the perimeter of the grocery store. This is where you find whole/unprocessed foods - meats, dairy, whole grains, fruits and veggies.

Chapters 11-13. Exercise, the most Powerful Longevity Drug!

As an exercise scientist, I want to thank Peter Attia for promoting ‘Exercise is Medicine’. Indeed, it’s a polypill and Attia is adamant about this statement as I’ve heard him state it several times on the podcast.

The Standard American Diet (SAD) is pretty sad and pathetic …. but so are our movement habits. 47% of U.S. adults meet the aerobic physical activity guidelines (150 minutes of moderate-intensity physical activity per week) and even fewer lift heavy shit and do resistance training. In combination, only 24% meet both aerobic and strength training recommendations.

Here’s the good news: a little goes a long ways. Moving from being a couch potato to just doing a little reduces the risk for morbidity and mortality. It's obvious that exercise is good for you .... that's not the revelation; what's amazing is the MAGNITUDE of the ASSOCIATION/EFFECT on health outcomes. In a side-by-side comparison of exercise vs. drug trials, exercise trials perform as well or better than drug interventions for CVD, diabetes, and stroke outcomes. Exercise IS medicine!

And, we need not argue about cardio vs. weights! This should not be an either/or this/that choice or argument ..... Both are beneficial and important.

Exercise is the behaviour. It’s what we do. The physical outcome of regular exercise is improved muscle mass (the engine for metabolism, strength and fitness) + Strength + Vo2max - all key determinants of health and chronic disease outcomes.

Another key aspect of exercise is Stability. Attia defines it as “the subconscious ability to harness, decelerate or stop force" and claims it is the foundation for aerobic fitness and muscular strength. It’s the foundation of the house. If we have weakness or a lack of stability at a joint, this would be akin to having poor tires on a race car.

Three keys to stability are:

• Breathing - the cylinder stabilizes the spine

• The Feet (the tires)- grounded to the earth

• The Hands - interface with the world & transmit force; hence, the importance of grip strength

Finally, if Exercise is Medicine, how can we prepare for being what Attia calls the ‘Centenarian Decathlete’? What is a good exercise prescription? Attia suggests:

• Aerobic exercise [4x/wk 45min in Zone 2 or 60-70% of your maximum heart rate or at a pace that is easy, able to have a conversation - talk test; plus 1-2x per week high-intensity intervals]

• Strength Training. Lift heavy; squat or deadlift, hinge, push and pull, grip (Farmer’s Carry), hang, and sometime ruck. 2-3x per wk

• Stability a few times per week before or after training or as recovery day

Chapter 16. Sleep, the best medicine for the Brain

We just finished stating that exercise and physical fitness is so key to health. Who better to have on the poster for fitness than a Navy SEAL?! Few will question their physical fitness. But, draw their blood and it might look like “old-man blood”. What does that mean? It means it shows a poor hormonal profile and elevated inflammatory markers - both indicators of poor overall fitness and health.

Why? They are under-recovered and sleep deprived.

In the past several years, the importance of sleep on health and performance has come to light. Several studies have now documented the links between poor sleep and several chronic diseases including the Four Horsemen, altered daily cognitive function (we’ve all experienced it), and diminished functional performance.

Similar to evaluating your nutrition, physical activity, body composition, and CVD risk factors, you should assess and monitor your sleep. Several commercial devices, wearable technology and beds, are available - some better than others.

It is very important to know your chronotype - are you a night owl or early bird? And please don’t try to wear the badge of courage of early bird when you are not.

It is important to create an optimal sleep environment. Here are a few key features:

• Darkness. You should not be able to see your hand in front of your face. Hint: room darkening shades.

• A cool room temperature (60-68 degree F)

• Avoid alcohol after 6PM

• Wind down at the end of the day and create a bedtime routine

• Avoid screen time, especially social media scrolling, a few hours before bed

Chapter 17. Emotional Health, don’t ignore it!

...striving for physical health and longevity (healthspan) is meaningless if we ignore emotional health.

First, mental health is not the same as emotional health. Emotional health is about regulating emotions and managing interpersonal relationships. Attia opens up and discusses his own emotional health issues. Peter is a highly successful person - undergraduate degree in mechanical engineering and applied math from Queen’s University; medical degree from Stanford; fellowships at John Hopkins and the National Cancer Institute; and now a highly regarded lifestyle medicine expert. And, he’s just like you and me - we all have challenges with regulating emotions and managing interpersonal relationships. We all have challenges with emotional health. And just like exercise, nutrition and sleep, we need to assess, plan, create goals, and strategies and take action at creating healthy relationships with ourselves and others.

For me, this last chapter provided perhaps my favorite nugget: Eulogy virtues > resume virtues. I’ll just leave this hang here for you to think about.

Be well. Peace.