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

by Peter Attia

There comes a point where we need to stop just pulling people out of the river. We need to go upstream and find out why they’re falling in. —BISHOP DESMOND TUTU

Longevity does not mean living forever. Or even to age 120, or 150, which some self-proclaimed experts are now routinely promising to their followers. Barring some major breakthrough that, somehow, someway, reverses two billion years of evolutionary history and frees us from time’s arrow, everyone and everything that is alive today will inevitably die. It’s a one-way street. Nor does longevity mean merely notching more and more birthdays as we slowly wither away.

they don’t want to live longer, if doing so means lingering on in a state of ever-declining health. Many of them have watched their parents or grandparents endure such a fate,

In 1900, life expectancy1 hovered somewhere south of age fifty, and most people were likely to die from “fast” causes: accidents, injuries, and infectious diseases of various kinds. Since then, slow death has supplanted fast death.

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.

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,

Healthspan is typically defined as the period of life when we are free from disability or disease, but I find this too simplistic. I’m as free from “disability and disease” as when I was a twenty-five-year-old medical student, but my twenty-something self could run circles around fifty-year-old

problem was that we approached both sets of patients—trauma victims and chronic disease sufferers—with the same basic script. Our job was to stop the patient from dying, no matter what.

Modern medicine has thrown an unbelievable amount of effort and resources at each of these diseases. But our progress has been less than stellar,

in every case, we are intervening at the wrong point in time, well after the disease has taken hold, and often when it’s already too late—

None of our treatments for late-stage lung cancer has reduced mortality by nearly as much as the worldwide reduction in smoking that has occurred over the last two decades, thanks in part to widespread smoking bans.

Type 2 diabetes offers a perfect example of this. The standard-of-care treatment guidelines of the American Diabetes Association specify that a patient can be diagnosed with diabetes mellitus when they return a hemoglobin A1c (HbA1c) test resultfn1 of 6.5 percent or higher, corresponding to an average blood glucose level of 140 mg/dL (normal is more like 100 mg/dL, or an HbA1c of 5.1 percent).

But if their HbA1c test comes back at 6.4 percent, implying an average blood glucose of 137 mg/dL—just three points lower—they technically don’t have type 2 diabetes at all. Instead, they have a condition called prediabetes,

We want to delay or prevent these conditions so that we can live longer without disease, rather than lingering with disease.

Medicine’s biggest failing is in attempting to treat all these conditions at the wrong end of the timescale—after they are entrenched—rather than before they take root.

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.

striving for physical health and longevity is meaningless if we ignore...

longevity demands a paradigm-shifting approach to medicine, one that directs our efforts toward preventing chronic diseases and improving our healthspan—and doing it now, rather than waiting until disease has taken hold or until our cognitive and physical function has already declined. It’s not “preventive” medicine; it’s proactive medicine, and I believe it has the potential not only to change the lives of individuals but also to relieve vast amounts of suffering in our society as a whole.

Risk is not something to be avoided at all costs; rather, it’s something we need to understand, analyze, and work with.

there have been two distinct eras in medical history, and that we may now be on the verge of a third.

Medicine 1.0. Its conclusions were based on direct observation and abetted more or less by pure guesswork, some of which was on target and some not so much.

much of Medicine 1.0 missed the mark entirely, such as the notion of bodily “humors,”

major contribution was the insight that diseases are caused by nature and not by actions of the gods,

Medicine 2.0 arrived in the mid-nineteenth century with the advent of the germ theory of disease,

led to improved sanitary practices by physicians and ultimately the development of antibiotics. But it was far from a clean transition;

shift from Medicine 1.0 to Medicine 2.0 was a long, bloody slog

The shift from Medicine 1.0 to Medicine 2.0 was prompted in part by new technologies such as the microscope, but it was more about a new way of thinking. The foundation was laid back in 1628, when Sir Francis Bacon first articulated what we now know as the scientific method.

Medicine 2.0 was transformational. It is a defining feature of our civilization, a scientific war machine that has eradicated deadly diseases such as polio and smallpox. Its successes continued with the containment of HIV and AIDS in the 1990s and 2000s, turning what had seemed like a plague that threatened all humanity into a manageable chronic disease.

Yet Medicine 2.0 has proved far less successful against long-term diseases such as cancer. While books like this always trumpet the fact that lifespans have nearly doubled since the late 1800s, the lion’s share of that progress may have resulted entirely from antibiotics and improved sanitation,

if you subtract out deaths from the eight top infectious diseases, which were largely brought under control by the advent of antibiotics in the 1930s, overall mortality rates declined relatively little over the course of the twentieth century.

for our cancer patients, time itself was the enemy. And we were always coming in too late.

The goal of this new medicine—which I call Medicine 3.0—is not to patch people up and get them out the door, removing their tumors and hoping for the best, but rather to prevent the tumors from appearing and spreading in the first place. Or to avoid that first heart attack. Or to divert someone from the path to Alzheimer’s disease.

doctors have traditionally relied on two tests to gauge their patients’ metabolic health: a fasting glucose test, typically given once a year; or the HbA1c test we mentioned earlier, which gives us an estimate of their average blood glucose over the last 90 days. But those tests are of limited use because they are static and backward-looking. So instead, many of my patients have worn a device that monitors their blood glucose levels in real time, which allows me to talk to them about nutrition in a specific, nuanced, feedback-driven way that was not even possible a decade ago. This technology, known as continuous glucose monitoring (CGM),

Medicine 3.0, in my opinion, is not really about technology; rather, it requires an evolution in our mindset,

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

Second, Medicine 3.0 considers the patient as a unique individual. Medicine 2.0 treats everyone as basically the same, obeying the findings of the clinical trials that underlie evidence-based medicine. These trials take heterogeneous inputs (the people in the study or studies) and come up with homogeneous results (the average result across all those people).

The third philosophical shift has to do with our attitude toward risk. In Medicine 3.0, our starting point is the honest assessment, and acceptance, of risk—including the risk of doing nothing.

The study reported a 24 percent relative increase4 in the risk of breast cancer among a subset of women taking HRT, and headlines all over the world condemned HRT as a dangerous,

nobody seemed to care that the absolute risk increase of breast cancer for women in the study remained minuscule. Roughly five out of every one thousand women in the HRT group developed breast cancer, versus four out of every one thousand in the control group, who received no hormones.

Yet this tiny increase in absolute risk was deemed to outweigh any benefits, meaning menopausal women would potentially be subject to hot flashes and night sweats, as well as loss of bone density and muscle mass, and other unpleasant symptoms of menopause—not to mention a potentially increased risk of Alzheimer’s disease,

The fourth and perhaps largest shift is that where Medicine 2.0 focuses largely on lifespan, and is almost entirely geared toward staving off death, Medicine 3.0 pays far more attention to maintaining healthspan, the quality of life.

Nearly all the money flows to treatment rather than prevention—and when I say “prevention,” I mean prevention of human suffering.

Which brings us to perhaps the most important difference between Medicine 2.0 and Medicine 3.0. In Medicine 2.0, you are a passenger on the ship, being carried along somewhat passively. 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. And you make important decisions. Because in this scenario, you are no longer a passenger on the ship; you are its captain.

For many people, like Sophie, the last ten years of life are not a particularly happy time. They typically suffer from one or more of the Horsemen diseases and the effects of the requisite treatments. Their cognitive and physical abilities may be weakening or gone. Generally, they are unable to participate in the activities they once loved, whether that means gardening, or playing chess, or riding a bicycle, or whatever else in their life gave them joy. I call this the Marginal Decade, and for many, if not most, it is a period of diminishment and limitation.

“Med 2.0.” You will live a bit longer, thanks to the relative comfort and safety of our lives. But in midlife, you will gradually begin to feel some changes. You will lose a bit of your youthful strength and stamina. You might notice that you occasionally forget passwords, or the names of people you meet, or the names of actors in movies you watched long ago. Your friends and peers will begin to be diagnosed with cancer, cardiovascular disease and related conditions like high blood pressure, and diabetes or prediabetes. You will attend memorial services for friends from school.

At a certain point, the decline begins to steepen. Eventually, sometime around age seventy or seventy-five, give or take, your cognitive and physical capacities will diminish to roughly their halfway point (represented by the horizontal dotted line), which I sort of arbitrarily define as the point below which you are no longer able to do the things that you want to do with ease. You’re constrained, and bad stuff starts to happen more frequently and with greater consequence.

This is where Medicine 2.0 steps in. We treat your heart disease, or cancer, or whatever else afflicts you, prolonging your life by a few months, or years if you’re lucky. This is when the lifespan/healthspan curve flattens out horizontally to the right, representing this postponement of death. But now look at where this occurs: when your healthspan is already compromised. This means that we have delayed your death without significantly improving your quality of life—something at which Medicine 2.0 is quite adept.

What’s our plan? This is where most people make a wrong turn. They want to take a shortcut, right to the tactics: this is what to eat (and not eat), that is how you should exercise, these are the supplements or medications you need, and so on.

To achieve our objectives, we first need to have a strategy: an overall approach, a conceptual scaffolding or mental model that is informed by science, is tailored to our goals, and gives us options.