10 Takeaways from Outlive by Peter Attia: How To Improve Healthspan & Lifespan
“Unfortunately, in today’s unhealthy society, ‘normal’ or ‘average’ is not the same as ‘optimal.’”
― Peter Attia
Outlive by Peter Attia, MD, explores the latest scientific research on longevity and offers practical advice on how to live longer and healthier. The book has been praised by experts for its comprehensive and evidence-based approach to longevity.
In Outlive, Attia discusses a number of different factors that can affect longevity, including diet, exercise, sleep, stress management, and social relationships. He also discusses the four horsemen of aging: cancer, dementia, type 2 diabetes, and CVD.
Attia argues that the goal of longevity should not be to simply extend lifespan, but to also extend healthspan. Healthspan is the number of years that you live in good health. Attia believes that by focusing on both lifespan and healthspan, we can live longer and healthier lives.
Outlive is a comprehensive and informative book that provides readers with the tools they need to live longer and healthier lives. The book is well-written and easy to understand, and it is packed with practical advice.
Takeaways From Outlive
1. Minimize Our Risk Exposure To The “Four Horsemen”
Peter Attia emphasizes the significance of starting early to prevent the "Four Horsemen," which represent the leading causes of death:
Cardiovascular disease
Cancer
Cerebral vascular disease (such as Alzheimer's)
Metabolic disease.
While advancements have been made in reducing deaths from heart disease, progress remains limited for the other three horsemen. Attia challenges the current healthcare business and disease risk models, arguing that they are inadequate for achieving the goal of a long and healthy life free from these ailments. He advocates for a shift towards calculating individuals' 50-year risk of cardiac disease rather than the traditional focus on the shorter term.
Attia provides comprehensive coverage of these disease as well as the importance of one major one plaguing today’s society: metabolic health. Shockingly, metabolic disorders, including diabetes, are significantly underdiagnosed, with millions of Americans affected, many of whom are unaware of their conditions. These alarming statistics underscore the urgency of addressing metabolic health as a central pillar in the quest for overall well-being.
Practical takeaway: He provides a lot of information to mitigate the risk of these four horsemen, many of which are below. One major one, however, is avoiding excessive fructose consumption. To do this, first and foremost, avoid drinking fruit juices and soda.
2. Monitor And Manage ApoB For Heart Health
“The various treatment guidelines specify target ranges for LDL-C, typically 100 mg/dL for patients at normal risk, or 70 mg/dL for high-risk individuals. In my view, this is still far too high. Simply put, I think you can’t lower apoB and LDL-C too much, provided there are no side effects from treatment. You want it as low as possible.”
― Peter Attia MD
Attia's concern about heart disease stems from personal experiences, witnessing his uncles' early deaths from the condition and detecting calcium on his heart scan in his 30s. Despite some skepticism about Big Pharma, Attia strongly advocates for the use of statins and PCSK9 inhibitors to improve blood lipid profiles, especially targeting ApoB, which he identifies as the primary culprit behind cardiovascular disease. In Chapter 7, titled "The Ticker," he delves into heart disease, discussing his family history of heart issues and the aggressive drug therapy he employs to manage his own early stages of cardiovascular disease.
One remarkable aspect of Peter's writing is his skillful use of metaphors to explain intricate topics. For example, he likens atherosclerosis to a scene of a crime, comparing the arterial wall to houses and the endothelium to fences in front of these houses, making the heart disease chapter informative and engaging.
Practical takeaway:
Measure ApoB and Lp(a) to complement LDL and HDL cholesterol assessments.
He recommends remarkably low LDL-C levels in the 10-20mg/dl range.
Learn more about ApoB and how to address it in his article here.
3. Exercise Is The Most Potent Pro-Longevity “Drug”
"Even a little bit of daily activity is much better than nothing. Going from zero weekly exercise to just 90 minutes per week can reduce your risk of died from all causes by 14%. It's very hard to find any drug that can do that."
—Peter Attia
Attia's perspective on exercise has evolved, now considering it the most potent longevity "drug" and ranking it above diet in importance. He emphasizes that exercise is dose-dependent for longevity, meaning the more you engage in it, the longer your healthspan and lifespan are likely to be. A study he cites involving over 750,000 U.S. veterans revealed that the least fit group had a four times greater risk of death compared to those in the top 2% of their age and sex category. This was more impactful than any cardiac risk factor.
“But if you really want to raise your VO2 max, you need to train this zone more specifically. Typically, for patients who are new to exercising, we introduce VO2 max training after about five or six months of steady zone 2 work.”
― Peter Attia
Practical takeaway: Peter advocates for a comprehensive fitness regimen, combining strength training with a mix of strength training, Zone 2 capacity, and VO2 max training. In essence, being in top shape during middle age is crucial to maintaining robust capacity as one ages, highlighting the importance of long-term health-focused exercise over athletic performance. For a complete breakdown on his weekly workout routine, look here. For how to get started in these main areas, and finding the minimum effective dose of strength training, Zone 2, VO2 Max training, and HIIT, click the links above.
4. Nutrition Is Important But Don’t Be Dogmatic.
Attia delves into the realm of nutritional biochemistry, avoiding specific diet labels and instead providing valuable insights. He advocates for a higher protein intake and highlights the significance of obtaining essential amino acids from our diet. Attia covers various energy substrates, cautioning against excessive alcohol consumption and putting carbohydrates into context, while also discussing the distinction between good and bad fats. Notably, he refrains from promoting supplements without substantial supporting evidence. Previously an advocate of the keto diet,
Attia now favors a more balanced and personalized approach to nutrition which often include one or more of the three approaches below.
Practical takeaway: One of his significant recommendations is a higher protein intake—twice the amount recommended by government guidelines—to support and enhance muscle mass in aging individuals. This comes out to one gram of protein per pound of body weight per day. He also discusses the three strategies for implementing nutritional biochemistry practically, including:
Calorie restriction
Dietary restrictions (e.g., paleo or vegan)
Time-restricted eating (fasting)
If you’re “overnourished” as he puts it, you need to pull one of these levers.
Source: erictopol.substack.com/p/a-review-of-outlive
5. Train For The Centenarian Olympics
The Centenarian Olympics is a personal competition against the body's natural decline. The goal is to stay as physically active and independent as possible as you age. In preparation for the Centenarian Olympics, Peter emphasizes the importance of identifying our aspirations for the last decade of our lives (the “marginal decade”) and working backward to train for those activities now. He specifically focuses on physical aspects, highlighting the need to build adequate muscle mass and tone to maintain independence and vitality later in life. As we age, we naturally lose muscle mass, making it crucial to establish a solid foundation during middle age to meet future physical demands. Attia encourages intentional training for activities we care about, whether it's playing with grandkids, hiking, or simply climbing stairs, and he helps individuals create tailored plans to achieve these goals.
He urges people to stop mindlessly exercising just for the sake of it, advocating for purposeful training to enhance strength and cardiovascular stamina. By envisioning the inevitable physical decline that comes with aging, Attia prompts us to take proactive measures today to ensure a more active and fulfilling life in the future.
Practical takeaway: He has a list of things that adults want to do when they're 100. Most of his patients want to do them all but he has them narrow them down to about 10 and then reverse engineer them. His conversations go something like this (paraphrased):
It's wonderful that you want to lift your grandkids. Although it might seem simple, it's like holding a 25 to 30 lb weight from a squat position right now. While this may be manageable at age 40, it's crucial to recognize that muscle strength naturally declines by 8 to 17% per decade, with acceleration over time. That means lifting 55 lb now at 40 years old if you want to lift that kid at 80 years old.
To learn more about this, listen to his podcast episode on the topic.
6. Sleep Is Critical
“The overarching point here is that a good night of sleep may depend in part on a good day of wakefulness: one that includes exercise, some outdoor time, sensible eating (no late-night snacking), minimal to no alcohol, proper management of stress, and knowing where to set boundaries around work and other life stressors.”
― Peter Attia
Reflecting on his experiences as a hard-charging doctor, Attia admits that many of his health challenges in his 30s were a result of poor sleep rather than just diet or exercise. In Chapter 16, titled "Sleep: The Awakening," he delves deep into the significance of sleep, proposing that it might be even more critical than exercise for overall well-being. He highlights the impact of sleep deprivation on metabolic health, increased cancer rates, accidents, and suicide. He references a study involving over 750,000 U.S. veterans, indicating that being physically unfit poses a greater risk of mortality than most cardiac risk factors, further emphasizing the importance of exercise for extending healthspan and lifespan.
Practical takeaways: He provides a lot of actionable advice on how to structure better sleep, which are all covered in articles I've written (below). He also suggests limiting or avoiding sleep medication for a variety of concerning reasons and instead, considering supplements such as glycine and ashwagandha.
Sleep Strategies:
7. Don't Neglect Emotional Health
“It took me a while to recognize this, but feeling connected and having healthy relationships with others, and oneself, is as imperative as maintaining efficient glucose metabolism or an optimal lipoprotein profile.”
—Peter Attia
In the final chapters of the book, Peter emphasizes the significance of emotional health in the pursuit of a fulfilling and extended healthspan. He candidly shares his own struggles with anger, relationship stress, and misplaced priorities, serving as a poignant reminder that prioritizing the wrong goals can lead to regret. Emotional well-being becomes the focal point of aging, with Attia asserting that a long life is not worth living if one is unhappy. He calls attention to the "epidemic of emotional health disorders" that acts as a significant obstacle to longevity for many of his patients.
Peter reveals his personal journey in seeking therapy, highlighting the positive impact of dialectical behavior therapy (DBT) on his emotional well-being. He underlines the importance of addressing emotional health as a preventive measure, likening it to the paradigm shift from Medicine 2.0 to Medicine 3.0, emphasizing long-term prevention akin to cardiovascular disease prevention. Maintaining emotional health becomes just as crucial as cognitive and physical maintenance.
Practical takeaway: Prioritize connectedness and healthy relationships as essential tools for managing glucose metabolism and maintaining an optimal lipoprotein profile. He emphasizes the correlation between loneliness and mortality risk, urging against isolation and encouraging people to foster meaningful connections to enhance emotional well-being and overall longevity.
Practice mindfulness, set aside time for friends and family, and seek help if appropriate.
8. Monitor And Improve Bone Density
Bone density plays a significant role in the puzzle of longevity. Protecting bone health becomes vital to slow its decline, especially as hip or femur fractures in individuals aged 65 or older have a significant mortality rate, ranging from 15% to 30% within one year, translating to one-third of people over 65 dying within a year of such fractures, often due to falls. Survivors may still encounter considerable setbacks in muscle mass and physical capacity as muscle loss accelerates during prolonged bed rest.
To assess bone health and diagnose osteopenia or osteoporosis, Peter advises his patients to undergo a yearly DEXA scan to measure bone mineral density (BMD). Although the standard guidelines recommend screening for women at 65 and men at 70, BMD naturally declines with age, mirroring the decline in muscle mass, which peaks in our late 20s before gradually decreasing. Menopause further hastens this decline in women due to reduced estrogen levels, which are essential for bone density in both men and women. Genetic factors, smoking history, corticosteroid use, medications blocking estrogen, low muscle mass, and undernourishment can contribute to low bone density.
Practical Takeaway: Strategies to Improve Bone Density:
Optimize Nutrition: Focus on protein and meet optimal nutritional needs and total energy requirements.
Engage in Heavy Load Bearing: Strength training with heavy weights stimulates bone growth better than impact sports like running (running is still better than swimming and cycling).
Consider Hormone Replacement Therapy (if indicated).
Use Bone Density-Increasing Drugs (if needed).
Attia says that bone density should be addressed by the first two strategies but they use the latter two if those are not sufficient.
9. Alcohol Is Not Good For Healthspan
“Despite what a lot of the epidemiology will tell people, alcohol is not good for you in any dose. It doesn’t mean we shouldn’t drink it at all, but let’s not delude ourselves into thinking it’s actually healthy at some low dose. It’s not.”
— Peter Attia
Alcohol offers no nutritional or health benefits and is especially disruptive for those who are overnourished. It provides empty calories without any nutritional value, delays fat oxidation, and often leads to mindless eating. Its net negative impact on longevity is linked to associations with Alzheimer's disease and potential negative effects on sleep (see above) and other mechanisms. While some studies suggest moderate alcohol consumption may improve cardiovascular health, heavier drinking reverses these benefits and is confounded by healthy user bias.
Practical takeaway: While he admits to occasionally having Spanish wine, Belgian beer, or Mexican tequila, he recommends limiting alcohol intake to less than seven servings per week and no more than two servings a day.
10. Stability Is Critical For Healthspan
I thought this chapter was going to be a boring take on the importance of core strengthening and improving strength but it may have had the most important takeaways for me. He introduces the topic by stressing the importance of this component. Stability is the foundation of good health and longevity. It is the ability of your body to maintain its balance and alignment, even when you are moving. Without stability, you are more likely to experience injuries, pain, and fatigue. This is, of course, backed up by scary stats with the TLDR being: if you don’t have stability your healthspan and lifespan are drastically shorter.
Practical takeaways:
The importance of the feet. Our feet are the foundation of our body, and they play a critical role in stability. Attia recommends using toe spacers to restore the natural spread of the toes, which can help improve proprioception (the sense of body position and movement). He also suggests doing cat-camel exercises to improve range of motion in the spine.
The importance of the shoulders. The shoulders are another important area for stability. Attia notes that evolution sacrificed stability in the shoulders for the ability to throw objects. To improve shoulder stability, he recommends dead hangs and scapular CARs (controlled articular rotations). These exercises help to improve neuromuscular control of the shoulder girdle.
See his video on these here.
The importance of grip strength. Grip strength is often overlooked, but it is essential for overall stability. Attia notes that grip strength is correlated with rotator cuff strength, and that a weak grip can lead to injuries. He also points out that the deadlift is as much about grip strength as it is about hamstring and glute strength.
One popular exercise for improving stability is the eccentrically based step-up. The step up exercise is performed by stepping up onto a platform, then slowly lowering yourself back down. The eccentric phase of the movement (the lowering phase) is particularly challenging for the stabilizing muscles.
See his video on this here.
Bonus
One of the biggest takeaways from this book is that it is never too late. Yup, it would have been better if you were lifting weights, limiting alcohol, and getting enough protein years ago but today is the next best time. You have a significant amount of control over your lifespan and healthspan including formidable opponents such as Alzheimer’s and cancer. What was formerly thought to be a consequence of the cards we were dealt (i.e. our genes) has now proven to be a consideration and not a determination.
What are your favorite lessons?
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