Outlive: The Science and Art of Longevity

by Peter Attia

the odds are overwhelming that you will die as a result of one of the chronic diseases of aging that I call the Four Horsemen: heart disease, cancer, neurodegenerative disease, or type 2 diabetes and related metabolic dysfunction. To achieve longevity—to live longer and live better for longer—we must understand and confront these causes of slow death.

Longevity has two components. The first is how long you live, your chronological lifespan, but the second and equally important part is how well you live—the quality of your years. This is called healthspan,

Almost all “diets” are similar: they may help some people but prove useless for most. Instead of arguing about diets, we will focus on nutritional biochemistry—

One macronutrient, in particular, demands more of our attention than most people realize: not carbs, not fat, but protein becomes critically important as we age.

Exercise is by far the most potent longevity “drug.” No other intervention does nearly as much to prolong our lifespan and preserve our cognitive and physical function. But most people don’t do nearly enough—and exercising the wrong way can do as much harm as good.

The time to repair the roof is when the sun is shining. —John F. Kennedy

This actually wasn’t so obvious until I’d spent my little sabbatical immersed in the worlds of mathematics and finance, thinking every day about the nature of risk. The banks’ problem was not all that different from the situation faced by some of my patients: their seemingly minor risk factors had, over time, compounded into an unstoppable, asymmetric catastrophe. Chronic diseases work in a similar fashion, building over years and decades—and once they become entrenched, it’s hard to make them go away. Atherosclerosis, for example, begins many decades before the person has a coronary “event” that could result in their death.

First, Medicine 3.0 places a far greater emphasis on prevention than treatment.

When did Noah build the ark? Long before it began to rain. Medicine 2.0 tries to figure out how to get dry after it starts raining. Medicine 3.0 studies meteorology and tries to determine whether we need to build a better roof, or a boat.

Medicine 3.0 pays far more attention to maintaining healthspan, the quality of life. Healthspan was a concept that barely even existed when I went to medical school. My professors said little to nothing about how to help our patients maintain their physical and cognitive capacity as they aged. The word exercise was almost never uttered. Sleep was totally ignored, both in class and in residency, as we routinely worked twenty-four hours at a stretch.

healthspan in particular, doesn’t really fit into the business model of our current healthcare system.

Health insurance companies won’t pay a doctor very much to tell a patient to change the way he eats, or to monitor his blood glucose levels in order to help prevent him from developing type 2 diabetes. Yet insurance will pay for this same patient’s (very expensive) insulin after he has been diagnosed.

there’s no billing code for putting a patient on a comprehensive exercise program designed to maintain her muscle mass and sense of balance while building her resistance to injury. But if she falls and breaks her hip, then her surgery and physical therapy will be covered.

Nearly all the money flows to treatment rather than prevention—and when I say “prevention,” I mean prevention of human suffering. Continuing to ignore healthspan, as we’ve been doing, not only condemns people to a sick and mis...

Medicine 3.0 demands much more from you, the patient: You must be well informed, medically literate to a reasonable degree, clear-eyed about your goals, and cognizant of the true nature of risk. You must be willing to change ingrained habits, accept new challenges, and venture outside of your comfort zone if necessary. You are always participating, never passive. You confront problems, even uncomfortable or scary ones, rather than ignoring them until it’s too late. You have skin in the game, in a very literal sense.

you are no longer a passenger on the ship; you are its captain.

Our tactics in Medicine 3.0 fall into five broad domains: exercise, nutrition, sleep, emotional health, and exogenous molecules, meaning drugs, hormones, or supplements.

we will break down this thing called exercise into its most important components: strength, stability, aerobic efficiency, and peak aerobic capacity.

I won’t be telling you to eat this, not that, or prescribing a specific diet that everyone should follow, and I’m definitely not taking sides in the pointless, never-ending diet wars pitting low carb versus paleo versus vegan, and so on. We will avoid such religious discussions in favor of biochemical evidence.

The best science out there says that what you eat matters, but the first-order term is how much you eat: how many calories you take into your body. How you go about achieving the Goldilocks zone here—not too much, not too little, but just right—will vary depending on numerous factors. My goal is to enable you to determine the best eating pattern for yourself.

Absorb what is useful, discard what is useless, and add what is specifically your own. —Bruce Lee

In Medicine 3.0, we have five tactical domains that we can address in order to alter someone’s health.

first is exercise, which I consider to be by far the most potent domain in terms of its impact on both lifespan and healthspan.

exercise is not just one thing, so I break it down into its components of aerobic efficiency, maximum aerobic output (...

Next is diet or nutrition—or as I prefer to call it, nutrit...

third domain i...

fourth domain encompasses a set of tools and techniques to manage and imp...

I want to focus on the other four domains, none of which were really covered, or even mentioned, in medical school or residency. We learned next to nothing about exercise, nutrition, sleep, or emotional health. That may be changing,

When I evaluate new patients, I’m always asking three key questions: a. Are they overnourished or undernourished? That is, are they taking in too many or too few calories? b. Are they undermuscled or adequately muscled? c. Are they metabolically healthy or not?

What follows is not a step-by-step plan to be followed blindly. There is no blanket solution for every person. Providing very granular exercise, dietary, or lifestyle advice requires individual feedback and iteration, something I can’t safely or accurately accomplish in a book. Rather, I hope you will learn a framework for managing your movement, nutrition, sleep, and emotional health that will take you much further than any broad prescription for how many grams of this or that macronutrient every single person on earth must eat.

This is exactly what I have meant in saying nutrition is an individual process

I’m constantly tinkering, experimenting, switching things up in my own regimen and in that of my patients. And my patients themselves are constantly changing.

We are not bound by any specific ideology or school of thought, or labels of any kind.

We range widely and pick and choose and test tactics that will hopefully work for us. We are open to changing our minds.

Should he be doing more cardio or more weights? What did I think?

Clearly, something about John’s question triggered me. It’s not that I was a passionate devotee of strength training over endurance, or vice versa; I’d done plenty of both. I was reacting to the binary nature of his question. In case you haven’t figured it out by now, I’m not fond of the way we reduce these complex, nuanced, vitally important questions down to simple either-ors. Cardio or weights? Low-carb or plant-based? Olive oil or beef tallow? I don’t know. Must we really take sides?

More than any other tactical domain we discuss in this book, exercise has the greatest power to determine how you will live out the rest of your life.

if you adopt only one new set of habits based on reading this book, it must be in the realm of exercise.

Going from zero weekly exercise to just ninety minutes per week can reduce your risk of dying from all causes by 14 percent. It’s very hard to find a drug that can do that.

dread going to parties, because when people find out what I really do for a living (not buying my usual lies about being a shepherd or a race car driver), they always want to talk about the topics I dread most: “diet” and “nutrition.”

Which brings us to my final quibble about the world of nutrition and diets, which is the extreme tribalism that seems to prevail there. Low-fat, vegan, carnivore, Paleo, low-carb, or Atkins—every diet has its zealous warriors who will proclaim the superiority of their way of eating over all others until their dying breath, despite a total lack of conclusive evidence.

one key change I have made is that I am no longer a dogmatic advocate of any particular way of eating, such as a ketogenic diet or any form of fasting. It took me a long time to figure this out, but the fundamental assumption underlying the diet wars, and most nutrition research—that there is one perfect diet that works best for every single person—is absolutely incorrect. More than anything I owe this lesson to my patients, whose struggles have taught me a humility about nutrition that I never could have learned from reading scientific papers alone.

CALORIC RESTRICTION, or CR: eating less in total, but without attention to what is being eaten or when it’s being eaten DIETARY RESTRICTION, or DR: eating less of some particular element(s) within the diet (e.g., meat, sugar, fats) TIME RESTRICTION, or TR: restricting eating to certain times, up to and including multiday fasting

From the standpoint of pure efficacy, CR or caloric restriction is the winner, hands down. This is how bodybuilders shed weight while holding on to muscle mass, and it also allows the most flexibility with food choices.

DR or dietary restriction is probably the most common strategy employed for reducing energy intake. It is conceptually simple: pick a type of food, and then don’t eat that food. It only works, obviously, if that food is both plentiful and significant enough that eliminating it will create a caloric deficit.

TR or time restriction—also known as intermittent fasting—is the latest trend in ways to cut calories. In some ways I think it’s the easiest.

The long and the short of it is that poor sleep can take a wrecking ball to both your long-term health and your ability to function day-to-day. When you look at the ripple effects of this, across a society that places as little value on sleep as I once did, a devastating picture emerges.

Just like exercise, sleep is its own kind of wonder drug, with both global and localized benefits to the brain, to the heart, and especially to our metabolism.

I read Terrence Real’s book I Don’t Want to Talk About It, a groundbreaking treatise on the roots of male depression. Once I started, I could not put it down. It was almost creepy that this guy seemed to be writing about me,

I had the same experience

“This Is Water”:

We are both drawn to this particular passage

“résumé virtues,” meaning the accomplishments that we list on our CV, our degrees and fellowships and jobs, versus “eulogy virtues,” the things that our friends and family will say about us when we are gone. And it shook me. For my entire life, I had been accumulating mostly résumé virtues. I had plenty of those. But I had also recently attended a funeral for a woman about my age who had died of cancer, and I was struck by how lovingly and movingly her family had spoken about her—with hardly a mention of her impressive professional or educational success. What mattered to them was the person she had been and the things she had done for others, most of all her children.