Outlive: The Science and Art of Longevity: The Million-Copy Bestseller

by Peter Attia

Study after study has found that regular exercisers live as much as a decade longer3 than sedentary people. Not only do habitual runners and cyclists4 tend to live longer, but they stay in better health, with less morbidity from causes related to metabolic dysfunction.

It turns out that peak aerobic cardiorespiratory fitness, measured in terms of VO2 max, is perhaps the single most powerful marker7 for longevity. VO2 max represents the maximum rate at which a person can utilize oxygen. This is measured, naturally, while a person is exercising at essentially their upper limit of effort. (If you’ve ever had this test done, you will know just how unpleasant it is.) The more oxygen your body is able to use, the higher your VO2 max.

That’s only the beginning. Someone in the bottom quartile of VO2 max10 for their age group (i.e., the least fit 25 percent) is nearly four times likelier to die than someone in the top quartile—and five times likelier to die than a person with elite-level (top 2.3 percent) VO2 max.

The strong association between cardiorespiratory fitness and longevity has long been known. It might surprise you, as it did me, to learn that muscle may be almost as powerfully correlated with living longer. A ten-year observational study13 of roughly 4,500 subjects ages fifty and older found that those with low muscle mass were at 40 to 50 percent greater risk of mortality than controls, over the study period. Further analysis revealed that it’s not the mere muscle mass that matters but the strength of those muscles, their ability to generate force.

Strength may even trump cardiorespiratory fitness, at least one study suggests.14 Researchers following a group of approximately 1,500 men over forty with hypertension, for an average of about eighteen years, found that even if a man was in the bottom half of cardiorespiratory fitness, his risk of all-cause mortality was still almost 48 percent lower if he was in the top third of the group in terms of strength versus the bottom third.

This is why I place such an emphasis on weight training—and doing it now, no matter your age. It is never too late to start; my mom did not begin lifting weights until she was sixty-seven, and it has changed her life. There are dozens of studies showing that strength training programs can significantly improve the mobility and physical function of subjects who are obese,25 or recovering from cancer treatment,26 even those who are already elderly and frail.

start by presenting my patients with a long list of physical tasks that might include some of the following: Hike 1.5 miles on a hilly trail. Get up off the floor under your own power, using a maximum of one arm for support. Pick up a young child from the floor. Carry two five-pound bags of groceries for five blocks. Lift a twenty-pound suitcase into the overhead compartment of a plane. Balance on one leg for thirty seconds, eyes open. (Bonus points: eyes closed, fifteen seconds.) Have sex. Climb four flights of stairs in three minutes. Open a jar. Do thirty consecutive jump-rope skips. The full list is much longer, with more than fifty different items, but you get the idea. Once they’ve read it I ask them to please select which of these tasks they want to be able to perform in their ninth, or better yet tenth, decade. Which ones do they choose? All of them, typically.

To lift that twenty-pound suitcase overhead when you are older means doing so with forty or fifty pounds now. To be able to climb four flights of stairs in your eighties means you should be able to pretty much sprint up those same stairs today. In every case, you need to be doing much more now, to armor yourself against the natural and precipitous decline in strength and aerobic capacity that you will undergo as you age.

The three dimensions in which we want to optimize our fitness are aerobic endurance and efficiency (aka cardio), strength, and stability. All three of these are key to maintaining your health and strength as you age. (And as we’ve seen, they also extend lifespan.) But both cardio and strength are far more nuanced than most people realize—and stability may be the least understood component of all.

healthy mitochondria are key to both athletic performance and metabolic health. Our mitochondria can convert both glucose and fatty acids to energy—but while glucose can be metabolized in multiple different ways, fatty acids can be converted to energy only in the mitochondria. Typically, someone working at a lower relative intensity will be burning more fat, while at higher intensities they would rely more on glucose. The healthier and more efficient your mitochondria, the greater your ability to utilize fat, which is by far the body’s most efficient and abundant fuel source. This ability to use both fuels, fat and glucose, is called “metabolic flexibility,”

When we are exercising in zone 2, most of the work is being done by our type 1, or “slow-twitch,” muscle fibers. These are extremely dense with mitochondria and thus well-suited for slow-paced, efficient endurance work. We can go for a long time without feeling fatigued. If we pick up the pace, we begin to recruit more type 2 (“fast-twitch”) muscle fibers, which are less efficient but more forceful. They also generate more lactate in the process, because of the way they create ATP. Lactate itself is not bad; trained athletes are able to recycle it as a type of fuel. The problem is that lactate becomes lactic acid when paired with hydrogen ions, which is what causes that acute burning you feel in your musclesfn1 during a hard effort.

increasing your VO2 max by any amount is going to improve your life, not only in terms of how long you live but also how well you live, today and in the future. Improving your VO2 max from the very bottom quartile to the quartile above (i.e., below average) is associated with almost a 50 percent reduction in all-cause mortality, as we saw earlier. I believe that almost anyone is capable of achieving this—and they should, because the alternative is so unacceptable.

The tried-and-true formula for these intervals is to go four minutes at the maximum pace you can sustain for this amount of time—not an all-out sprint, but still a very hard effort. Then ride or jog four minutes easy, which should be enough time for your heart rate to come back down to below about one hundred beats per minute. Repeat this four to six times and cool down.

Daily life and zone 2 endurance work may be enough to prevent atrophy of type 1 fibers—but unless you are working against significant resistance, your type 2 muscle fibers will wither away.

In its most extreme form, this muscle loss is called sarcopenia,18 as noted in chapter 11. Someone with sarcopenia will have low energy, feelings of weakness, and problems with balance. Sarcopenia is a prime marker for a broader clinical condition called frailty,19 where a person meets three of these five criteria: unintended weight loss; exhaustion or low energy; low physical activity; slowness in walking; and weak grip strength (about which more soon).

A far more important measure of strength, I’ve concluded, is how much heavy stuff you can carry.

Training grip strength is not overly complicated. One of my favorite ways to do it is the classic farmer’s carry, where you walk for a minute or so with a loaded hex bar or a dumbbell or kettlebell in each hand. (Bonus points: Hold the kettlebell up vertically, keeping your wrist perfectly straight and elbow cocked at ninety degrees, as though you were carrying it through a crowded room.)

No discussion of strength is complete without mentioning concentric and especially eccentric loading. Again, eccentric loading means loading the muscle as it is lengthening, such as when you lower a bicep curl. It’s more intuitive when lifting something to focus on the concentric phase, such as curling the dumbbell with your biceps. This is the strength of a muscle getting shorter.

In life, especially as we age, eccentric strength is where many people falter. Eccentric strength in the quads is what gives us the control we need when we are moving down an incline or walking down a set of stairs. It’s really important to keep us safe from falls and from orthopedic injuries. When we can eccentrically load our muscles, it also prevents our joints from taking excess stress, especially our knees.

Training eccentric strength is relatively simple. Big picture, it means focusing on the “down” phase of lifts ranging from pull-ups or pull-downs to deadlifts to rows; rucking downhill, carrying a weighted pack, is a great way to build both eccentric strength as well as spatial awareness and control, which are important parts of stability training (next chapter).

All of the above, the research and my own experience, support my first commandment of fitness: First, do thyself no harm. How do we do this? I think stability is the key ingredient.

In sum, stability lets us create the most force in the safest manner possible, connecting our body’s different muscle groups with much less risk of injury to our joints, our soft tissue, and especially our vulnerable spine. The goal is to be strong, fluid, flexible, and agile as you move through your world.

The easiest way to start this process is to get on your hands and knees and go through an extremely slowed-down, controlled Cat/Cow sequence, similar to the basic yoga poses of the same names.fn4

Nutrition is relatively simple, actually. It boils down to a few basic rules: don’t eat too many calories, or too few; consume sufficient protein and essential fats; obtain the vitamins and minerals you need; and avoid pathogens like E. coli and toxins like mercury or lead. Beyond that, we know relatively little with complete certainty.

Once you strip away the labels and the ideology, almost all diets rely on at least one of the following three strategies to accomplish this: 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

Limiting calories can be helpful for people who are metabolically unhealthy and/or overnourished. But I’m not convinced that whatever longevity boost long-term, deep caloric restriction may confer is worth some of the trade-offs—including potentially weakened immunity and greater susceptibility to cachexia and sarcopenia (muscle loss), not to mention constant hunger.

It’s easy to overlook, but alcohol should be considered as its own category of macronutrient because it is so widely consumed, it has such potent effects on our metabolism, and it is so calorically dense at 7 kcal/g (closer to the 9 kcal/g of fat than the 4 kcal/g of both protein and carbohydrate). Alcohol serves no nutritional or health purpose but is a purely hedonic pleasure that needs to be managed. It’s especially disruptive for people who are overnourished,

My personal bottom line: if you drink, try to be mindful about it. You’ll enjoy it more and suffer fewer consequences. Don’t just keep drinking because they’re serving it on the plane. I strongly urge my patients to limit alcohol to fewer than seven servings per week, and ideally no more than two on any given day, and I manage to do a pretty good job adhering to this rule myself.

We already know that it’s not good to consume excessive calories. In the form of carbohydrates, those extra calories can cause a multitude of problems, from NAFLD to insulin resistance to type 2 diabetes,

All things equal, it appears that sleeping just five to six hours (versus eight hours) accounts for about a 10 to 20 mg/dL (that’s a lot!) jump in peak glucose response, and about 5 to 10 mg/dL in overall levels.

Simply tracking my glucose has a positive impact on my eating behavior. I’ve come to appreciate the fact that CGM creates its own Hawthorne effect, a phenomenon where study subjects change their behavior because they are being observed. It makes me think twice when I see the bag of chocolate-covered raisins in the pantry, or anything else that might raise my blood glucose levels.

Unlike carbs and fat, protein is not a primary source of energy. We do not rely on it in order to make ATP,fn8 nor do we store it the way we store fat (in fat cells) or glucose (as glycogen). If you consume more protein than you can synthesize into lean mass, you will simply excrete the excess in your urine as urea.

The twenty amino acids that make up proteins are the building blocks for our muscles, our enzymes, and many of the most important hormones in our body. They go into everything from growing and maintaining our hair, skin, and nails to helping form the antibodies in our immune system. On top of this, we must obtain nine of the twenty amino acids that we require from our diet, because we can’t synthesize them.

How much protein do we actually need? It varies from person to person. In my patients I typically set 1.6 g/kg/day as the minimum, which is twice the RDA. The ideal amount can vary from person to person, but the data suggest that for active people with normal kidney function, one gram per pound of body weight per day19 (or 2.2 g/kg/day) is a good place to start—

The distribution of amino acids is not the same as in animal protein. In particular, plant protein has less of the essential amino acids methionine, lysine, and tryptophan, potentially leading to reduced protein synthesis. Taken together, these two factors tell us that the overall quality of protein derived from plants is significantly lower than that from animal products.

While carbohydrates are primarily a source of fuel and amino acids are primarily building blocks, fats are both. They are very efficient fuel for oxidation (think: slow-burning logs) and also the building blocks for many of our hormones (in the form of cholesterol) and cell membranes. Eating the right mix of fats can help maintain metabolic balance, but it is also important for the health of our brain, much of which is composed of fatty acids.

There are (broadly) three types of fats: saturated fatty acids (SFA), monounsaturated fatty acids (MUFA), and polyunsaturated fatty acids (PUFA).fn9 The differences between these have to do with differences in their chemical structure; a “saturated” fat simply has more hydrogen atoms attached to its carbon chain.fn10 Within PUFA, we make one more important distinction, which is to separate the omega-6 from the omega-3 variants (also a chemical distinction having to do with the position of the first double bond). We can further subdivide omega-3 PUFA into marine (EPA, DHA) and nonmarine sources (ALA). Salmon and other oil-rich seafood provide the former, nuts and flaxseed the latter.

The default fat state of most of my patients (i.e., their baseline fat consumption when they come to me) works out to about 30–40 percent each of MUFA and SFA, and 20–30 percent PUFA—and within that PUFA group, they are generally consuming about six to ten times more omega-6 than omega-3s and usually scant amounts of EPA and DHA. From our empirical observations and what I consider the most relevant literature, which is less than perfect, we try to boost MUFA closer to 50–percent, while cutting SFA down to 15–20 percent and adjusting total PUFA to fill the gap. We also boost EPA and DHA, those fatty acids that are likely important to brain and cardiovascular health, with marine fat sources and/ or supplementation.

Putting all these changes into practice typically means eating more olive oil and avocados and nuts, cutting back on (but not necessarily eliminating) things like butter and lard, and reducing the omega-6-rich corn, soybean, and sunflower oils—while also looking for ways to increase high-omega-3 marine PUFAs from sources such as salmon and anchovies.fn12

In the final analysis, I tell my patients that on the basis of the least bad, least ambiguous data available, MUFAs are probably the fat that should make up most of our dietary fat mix, which means extra virgin olive oil and high-MUFA vegetable oils. After that, it’s kind of a toss-up, and the actual ratio of SFA and PUFA probably comes down to individual factors such as lipid response and measured inflammation. Finally, unless they are eating a lot of fatty fish, filling their coffers with marine omega-3 PUFA, they almost always need to take EPA and DHA supplements in capsule or oil form.

while we are in deep sleep, the brain activates a kind of internal waste disposal system that allows cerebrospinal fluid to flood in between the neurons and sweep away intercellular junk; while this happens, the neurons themselves pull back to allow this to happen, the way city residents are sometimes required to move their cars to allow street sweepers to pass through. This cleansing process flushes out detritus, including both amyloid-beta and

Light is the enemy of sleep, full stop. Thus, you want to make your bedroom itself as dark as possible—installing room-darkening curtains if you live somewhere with a lot of outdoor evening light, and removing all light sources in the bedroom, even down to electronic equipment like TVs and cable boxes and such. Their little pinpoint LEDs are more than bright enough to keep you from sleeping well.

Many people associate sleep with warmth, but in fact the opposite is true: One of the signal events64 as we are falling asleep is that our body temperature drops by about one degree Celsius. To help that happen, try to keep your bedroom cool—around sixty-five degrees Fahrenheit seems to be optimal. A warm bath before bed may actually help with this process, not only because the bath itself is relaxing but also because when we get out of the bath and climb into our cool bed, our core temperature drops,

Coffee is not a solution to the problem of poor sleep, especially if consumed to excess or (especially) at the wrong time. Most people think of caffeine as a stimulant67 that somehow gives us energy, but actually it functions more as a sleep blocker. It works by inhibiting the receptor for a chemical called adenosine, which normally helps us go to sleep every night. Over the course of the day, adenosine builds up in our brain, creating what scientists call “sleep pressure,” or the drive to sleep. We may be tired and needing sleep, but if we ingest caffeine it effectively takes the phone off the hook, so our brain never gets the message.

Don’t drink any alcohol, period—and if you absolutely, positively must, limit yourself to one drink before about 6 p.m. Alcohol probably impairs sleep quality more than any other factor we can control. Don’t confuse the drowsiness it produces with quality sleep. Don’t eat anything less than three hours before bedtime—and ideally longer. It’s best to go to bed with just a little bit of hunger (although being ravenous can be distracting.) Abstain from stimulating electronics, beginning two hours before bed. Try to avoid anything involving a screen if you’re having trouble falling asleep. If you must, use a setting that reduces the blue light from your screen. For at least one hour before bed, if not more, avoid doing anything that is anxiety-producing or stimulating, such as reading work email or, God help you, checking social media. These get the ruminative, worry-prone areas of our brain humming, which is not what you want. For folks who have access, spend time in a sauna or hot tub prior to bed. Once you get into the cool bed, your lowering body temperature will signal to your brain that it’s time to sleep. (A hot bath or shower works too.) The room should be cool, ideally in the midsixties. The bed should be cool too. Use a “cool” mattress or one of the many bed-cooling devices out there. These are also great tools for couples who prefer different temperatures at night, since both sides of the mattress can be controlled individually. Darken the room completely. Make it d...

One reason this approach has proved less effective in the psychological realm is that mental health and emotional health are not the same thing. Mental health encompasses disease-like states such as clinical depression and schizophrenia, which are complex and difficult to treat but do present with recognizable symptoms. Here, we are more interested in emotional health, which incorporates mental health but is also much broader—and less easy to codify and categorize.

I was ready to give up when Esther suggested that I read Terrence Real’s book10 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, despite never having met me. His main thesis is that with women, depression is generally overt, or obvious, but men are socialized to conceal their depression, channeling it inward or into other emotions, such as anger, without ever wanting to discuss it.

“Family pathology rolls from generation to generation like a fire in the woods taking down everything in its path until one person, in one generation, has the courage to turn and face the flames. That person brings peace to his ancestors and spares the children that follow.”