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As promised my review of Peter Attia's Outlive.
For those of you that don’t know me in real life, I’m a biologist by trade. For at least the past five years of my PhD, I’ve been absolutely obsessed with understanding fat metabolism and metabolic dysfunction. Heart, or cardiovascular disease (CVD) is still the #1 global killer, despite decades of research and the existence of a very effective class of drugs that largely treat the condition. CVD is thought to be largely caused by dysfunctions in metabolism, which is also true to some extent for the other three largest killers in the west: diabetes, cancer, and dementia. While traditional medicine has had a ton of success eradicating traditional infectious diseases, it seems largely unable to effectively treat these “four horseman”, despite the billions of dollars that have been poured into research and the development of thousands of pharmaceuticals. A reactive, treatment-focused approach isn’t working: we need something new.
This is where Peter Attia’s Outlive comes in. Unlike other longevity books like David Sinclair’s Lifespan, Outlive is relatively light on pharmaceuticals and lifespan extension. Lifespan extension doesn’t seem very tractable in humans currently: even the massive advances in public health, germ theory of disease, and antibiotics did little to increase the maximum age of death: the increase in life expectancy of what Attia calls medicine 2.0 rather came from massively reducing child mortality and the impact of infectious disease across all age brackets. While there is some promising research in animal models on lifespan extension, and Bryan Johnson is attempting to biohack himself into immortality, neither Attia nor myself think that focusing on this kind of stuff as an individual is very useful. Rather, Attia is focused on lifestyle interventions to prevent and delay the onset of the four horseman (CVD, diabetes, cancer, dementia), effectively increasing the healthy years of one’s life, or healthspan.
Outlive is divided into two sections. In the first, Attia gives an overview of the mechanism of action of the four horseman in order of lethality. This is the only part of the book in which pharmaceuticals are mentioned, mainly in relation to CVD and diabetes, that can be well-managed by statins (CVD)[1] and drugs like metformin (diabetes). I generally liked these sections, although there was frustratingly little information about dementia, likely due to our poor understanding of the disease. The common thread that seems to tie all four of these horseman together, including cancer and dementia, is dysregulated metabolism, which is also the central theme of Attia’s practical recommendations in the second half of the book. This section is divided into roughly into four, with the book highlighting lifestyle changes with regards to exercise, nutrition, sleep, and emotional well-being. Like with the first section, I broadly agree with Outlive’s prescription, although I have some quibbles with some of the details. More on each of these below.
Exercise
I originally discovered Peter through an interview with Iñigo San Millan, who is most famous for being cycling super-star Tadej Pogacar’s coach. Iñigo is a professor at University of Colorado (of course he is), who works on understanding what the metabolism of athletes can tell us about metabolic disease. Millan has shown, perhaps unsurprisingly, that athletes are far more insulin sensitive, and have far more of an ability to burn fat than both untrained and metabolically unhealthy people. They obtain these adaptions through a ton of exercise in what psychologists term Zone 2, which is done at a relatively pedestrian pace. This exercise in Zone 2 forms the basis of Peter’s prescriptions.
In addition to preventing the four horseman, the focus on Outlive in this section is on what Peter dubs the “centenarian decathlon”. These are a group of activities that you would like to be able to still do when you are 100 (or 80 or 90). In addition to the aerobic capacity developed by zone 2 exercise, which is necessary for actives like hiking or even walking, you also need to develop maintain muscular strength and coordination, as well as max aerobic capacity, also known as Vo2 max. Peter recommends roughly 6 hours of exercise a week, composed of a few weight lifting sessions, something like yoga for mobility, 2-3 Zone 2 sessions, and a hard Vo2 max workout. This is much more than the amount of exercise that most of us are doing, and much more than the current medical establishment recommends.
I don’t that this is a bad plan: certainly it’s better than doing nothing. But I worry that what Peter recommends is too intense, especially for someone who hasn’t really done much exercise before. What Outlive defines as Z2, right around the first lactate threshold of 1.5-2 mmol is pretty intense exercise, and will rely heavily on sugar, especially as an untrained athlete. Vo2 max work and the gym are also intense and heavily glycolytic. Instead of training your body to better burn fat, you may be creating massive amounts of sugar cravings. Since this program is also quite intense, I would imagine compliance might be an issue as well, potentially leaving you in a worse place that you started.
I would instead recommend a program like one Gordo Byrn outlines in this post: 4 hours of Z1 before the first lactate threshold, 30 minutes of higher intensity, an hour of gym work, and thirty minutes of mobility/agility a week. For an unfit person, even something like walking may be in that first zone. This plan will generally be much gentler on your nervous system, and will properly train your metabolism so you avoid CVD and diabetes like Peter intends.
I would also like to put in a small plug for barefoot shoes. I’ve been interested in them for years, but I was prompted to take the plunge by the recommendation of my friend. I’ve been wearing barefoot shoes to work and out and about for the past three months, and there has been a huge improvement in my balance and agility. Even my arch has returned. I haven’t done much running in them yet, but that will come!
Nutrition
One of the reasons I have such high respect for Peter is his ability to change his mind. Mid-2010s Peter would have put this section first and used it to advocate for the ketogenic diet. However, there just isn’t evidence for the effectiveness of this diet, nor really of any other diet for longevity: Peter is skeptical of epidemiological studies because of their inability to control for confounding variables. While I think he comes down too harsh on epidemiology, I largely agree. Diet is so individualized that it’s difficult to make prescriptions about what to and not to eat. As a result of this uncertainty, this section ends up being a little sparse on detailed advice. Avoid large caloric surpluses or deficits, avoid behaviors that spike your blood glucose and blood lipids, and make sure to eat enough protein to build muscle mass. All very non-objectionable, although I think Peter’s protein targets are a little aggressive. Protein is readily interconverted into sugar, and if you aren’t using it to build muscle you’re just going to be stressing your kidneys and raising your blood sugar. Plus high protein intake (beyond the needs of muscle synthesis) is associated with shorter lifespan in humans and pretty much every single model organism. I wouldn’t go much over 1g/lb of body weight, which is upper limit for more effective muscle synthesis.
Sleep
This chapter was also very non-objectionable. Get your 7-9 hours. Make sure you create a relaxed environment on both sides of sleep. Don’t track sleep if it stresses you out. I’m coming off a period of being too stressed out by my sleep tracking, so I’m trying to only focus on giving myself 9 hours in bed, and not worrying.
Emotional
I’m glad Attia included this chapter in Outlive, as I think it’s very important to consider why we want to live longer. Without joy, community, and love, increasing health and lifespan starts to increasingly look like Voldemort creating Horcrux’s while destroying every relationship that could have made his life better However, I didn’t find this chapter to be incredibly informative, most likely because Peter is a total newbie in this area. There’s a fuzzy recommendation for some kind of therapy, or at the very least self-directed CBT. The aim of this seems to be to understand environmental triggers for negative (and I suppose positive) emotional reactions and outbursts that ruin relationships and fix them. I don’t think this a bad idea, but I would appreciated more direction, and also more of a focus on the importance of social connection. As one of my friends in Baltimore keeps pointing out, loneliness can be as damaging as smoking a pack of cigarettes a day. This is an aspect of longevity that was not addressed at all in this book.
Conclusion
Despite my quibbles, I think Outlive is the most solid and accessible longevity book on the market. Attia grounds his prescriptions in the tangible goals of chronic disease prevention and the centenarian olympics, and the advice he gives is practicable and actionable. While I wish that he would have touched more on the emotional and social aspects of healthy aging, he at least acknowledges the former and likely will feature more guests on his podcast The Drive that deal with this aspect of health.
Thank you for the write-up.
Longevity / health has been an interest since I read Lustig's Metabolical. FWIW, Lustig does a good job of getting into the details of how the macros (fat, protein, and carbohydrates) interact to fuel you - or to cause metabolic syndrome, "leak gut", and all sorts of insulin issues. The transfats section was particularly scary.
On the Zone 2 exercise claims. I've seen these floating around health twitter for sometime. I cannot at all claim to be an expert, but I think some of the confusion may come down to the fact that the difference between Z2 for multi-year trained folks and those just coming off the couch can be massive. The reality is that most people, even those who go to the gym regularly, are actually very undertrained in a whole-of-athlete sense. Gym Bros can move big weight, but they have the cardio of smokers. Treadmill bunnies can stomp out 7 min miles for ever, but have heart palpitations after doing a few box jumps or kettlebell swings. Casual gym goers train themselves into hyperspecialization which leads to overall system brittleness. I think that's hard for people to deal with because it means treating your fitness as a dynamic system that changes meaningfully every six or so months. The only people who are going to be able to keep up with that are already in the top 20% of executive function / discipline / planning capability - which means they likely are already doing it! It's such a hard problem for that 50% - 80%. It's an impossibility for < 50%.
Agree broadly on nutrition. There's no special diet. You eat whole, minimally processed foods, with roughly balanced fat-protein-carbs. I think anything from 40-30-30 (fat protein carbs) to 20-50-30 (fat protein carbs) is probably fine and mostly rests on an individuals particular sensitivities and situation. Any diet where a macro is less than 15% if total calories seems suspicious to me. The protein cult is real. You cite 1g / lb of bodyweight as a max. I've seen references to 0.8 g / lb as where diminishing returns start. If you're really getting after it in the gym or elsewhere (marathon runner etc.) then going above 0.8 can have benefit.
Sleep is king. Got disciplined with it about 18 months ago. Perhaps as much of an impact on mental and physical health as a good gym routine. After a while, I started to really enjoy the end of day pattern I had constructed for myself to signal sleep to my brain and body.
Emotional. Again, person to person. There are recluses out there who do perfectly fine on their own, but they are an exception. Definitely against the "everyone should go to therapy" line. Pretty good way to develop neuroticism. I think the gold standard is a religious community. You get a deeply committed community aligned to a transcendental or metaphysical "goal." That's self-sustaining in a permanent way that a softball beer league or trivia night group is not.
Yea I think the confusion on Z2 comes from the fact that in highly trained athletes, Z2 is heavily fat burning still. As you get fitter you can handle more intensity without it cooking you. Same with strength. What Gordo and I advocate for is a volume first approach where you focus on time exercising first and then worry about intensity. Of course not appealing in current milieu because people don't want to spend the time exercising that is required to be fit. Weight lifting and cardio are both important as you say, which means even more time.
I think you might be a little bit heavy on the protein still, but I broadly agree.
Sleep really is key. The biggest problem I have with it is that my cronotype is much earlier than most of the population, so I get a ton of shit for wanting to go to bed earlier.
Also agree with religion as an alternative to therapy, although I unfortunately don't find the versions of Christianity around me to be very appealing. I want a more environmental-focused version of christianity basically, but the only communities that I see doing that are a bunch of wokies. I also agree therapy isn't the answer. Perhaps it would be if therapists actually wanted to cure people, but it seems like the current profit model leads to people spinning their wheels forever and using "childhood trauma" as an excuse to never change.
I've heard a minimum of 0.8 g/kg for an active person (roughly ~.4 g/lb). The max dose with a shown benefit for performance is 2.2 g/kg, which is 1g/lb. So making sure you get at least 0.5 g a day seems good, and not more than 1g/lb, especially if you aren't training intensely. This likely means protein in the 80-200 g range for most of us.
It's been a problem with every single girl I've dated. I've decided to bite the bullet one day a week and have no limit on bed time, but it's still difficult. Going to sleep at 10pm most nights, and between 11-1am one night a week, which usually fucks me.
I'll look into it, especially when I move away from Baltimore. Just tired of the options here, which are either extremely woke or extremely trad.
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