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Notes -
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.
which one did you get? and did you start abruptly or gradually?
Gradually. Started wearing them around the house at first, then to work one day a week, then two, three, etc. Going to start running in them once a week once snow melts.
I have these. Very comfortable, they feel like slippers.
Seconded, I liked they're product so much that I bought a bunch of pairs that are sitting in my closet, against the day they fuck with them and they don't fit me properly anymore.
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