[WIP] Outlive: The Science and Art of Longevity (Peter Attia)
A groundbreaking manifesto on living better and longer that challenges the conventional medical thinking on aging and reveals a new approach to preventing chronic disease and extending long-term health, from a visionary physician and leading longevity expert.
Wouldn’t you like to live longer? And better? In this operating manual for longevity, Dr. Peter Attia draws on the latest science to deliver innovative nutritional interventions, techniques for optimizing exercise and sleep, and tools for addressing emotional and mental health.
These are my reading notes from this book, and are a work in progress. All errors, omissions, and misrepresentations are mine.
Chapter 1: The Long Game – From Fast Death to Slow Death
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
Death comes at two speeds: fast and slow. In contrast to gunshot wounds and stabbings, slow-growing conditions like cancer can progress insidiously, and by the time they're discovered could be too late for even the best surgeons to treat.
A century ago, fast death was the most common cause of death; now it's the Four Horsemen of slow death: heart disease, cancer, neurodegenerative disease, and type 2 diabetes/metabolic dysfunction.
Medicine even now is more effective on fast than slow death – we can fix serious spine and brain injuries, replace damaged organs, and wipe out infections with powerful antibiotics – but our approach to chronic diseases is more reactive than proactive, more about relieving symptoms than preventing them in the first place. We're intervening at the wrong point in time, after the disease has already taken hold. By the time we get to a clinical diagnosis (e.g. when a patient's HbA1c test result reaches 6.5%, signifying type 2 diabetes) we're already very late in the game.
This book is about longevity. But there are two ways of measuring longevity:
- Your lifespan, or how long you live. Science has not yet made major breakthroughs allowing us to live to age 150, and oftentimes our later years are plagued with ever-declining health and suffering.
- Your healthspan, in contrast, measures how long you maintain your physical and mental function, staying free of disability and disease.
Disappearing down the road to physical disability, dementia, or long-term disease isn't any of our ideal futures. We want to delay or prevent chronic conditions so we can live longer without disease, rather than lingering with disease. The best way to prevent that is to start thinking about it and taking action now.
Each of the Four Horsemen is complex, a product of multiple risk factors compounding over time. Many of those individual risk factors are relatively easy to reduce or eliminate. And many of these risk factors are vulnerable to the same tactics and behavioral changes in this book.
Chapter 2: Medicine 3.0 – Rethinking Medicine for the Age of Chronic Disease
The time to repair the roof is when the sun is shining.
John F. Kennedy
Medicine is conservative in nature, rooted in tradition and resistant to change and innovation. The author found this out when he was reprimanded for giving a patient livesaving medicine at the appropriate time mathematically, before its scheduled time (when the next nursing shift was due to arrive).
"First, do no harm" (which Hippocrates didn't say anyway) exemplifies the culture of medicine now, which takes the wrong approach with risk. Sometimes risk is significantly asymmetric – doing some harm to prevent a much larger one (e.g. death) is warranted.
One of the most egregious examples of medicine getting risk wrong is with hormone replacement therapy (HRT) for postmenopausal women. In 2002 a large clinical trial reported a 24% increase in breast cancer risk in a subset of women taking HRT, and the therapy almost instantly became taboo worldwide as dangerous, cancer-causing. But that risk increase was relative – only a 0.1% increase in absolute terms – yet was deemed to outweigh any benefits, such as preventing hot flashes, night sweats, loss of bone density and muscle mass, and even Alzheimer's disease.
Medicine has gone through three phases in history.
Medicine 1.0, exemplified by Hippocrates and lasting for another two thousand years after his death, was based on direct observation and guesswork.
Medicine 2.0 started in the mid-19th century with the germ theory of disease, though it took centuries to take hold – Semmelweis, who theorized that doctors themselves were passing illness by not washing their hands, was ostracized by the medical community and died in an insane asylum.
With Medicine 2.0 came a new way of thinking – the scientific method: observing, forming a hypothesis, then rigorously testing that hypothesis to determine if it's correct. Penicillin's discovery in 1928 paved the way for the eradication of polio and smallpox, containment of HIV/AIDs in the 1990s, curing hepatitis C, and the rapid development of several effective vaccines against COVID-19 not even a year after the pandemic started.
But Medicine 2.0 has proven far less successful against the Four Horsemen. Over the last century, mortality rates for infectious diseases declined precipitously (due to antibiotics and improved sanitation), but relatively little otherwise. Medicine 2.0 comes in too late – risk factors like atherosclerosis can begin many decades before the person has a heart attack or stroke, but modern medicine only intervenes after that cardiac "event".
Medicine 3.0 aims to maintain healthspan, the quality of life. It aims to not remove people's tumors and hope for the best, but prevent them in the first place. It treats each patient as a unique individual, instead of relying solely on homogeneous results, the averaged out findings from clinical trials. It determines how each patient is similar or different from "average" and concludes how relevant the trial's results are.
Medicine 3.0 lets us ask how risk and reward balance out on an individual level. How similar or different is our patient from the cohorts studied in the aforementioned HRT clinical trial, and so how relevant are its results?
We have technology now that helps (like continuous glucose monitors/CGMs that can provide visibility into your individual metabolism, as opposed to once-yearly fasting glucose or HbA1c tests) but we're still far from precision medicine, from nanobots injected to treat disease. But Medicine 3.0 isn't about technology; it's a difference in approach.
Longevity and healthspan don't really fit in the business model of our current healthcare system. There are few insurance reimbursement codes for preventative interventions; health insurance companies will pay for (very expensive) insulin after type 2 diabetes diagnosis but not to tell the patient to change the way they eat or monitor their blood glucose levels beforehand.
The Titanic sank because of multiple factors, including ignored telegraph warning messages and the lookout's binoculars locked up with no key. Modern tech like radar and sonar, or GPS and satellite imaging, would have prevented the sinking days in advance. Medicine 3.0 requires looking through a longer lens as well – looking at our 30 or 40 year cardiovascular risk profile, not just the ten-year risk we measure in even the longest clinical trials.
Medicine 3.0 requires the patient to be actively involved – well informed, reasonally medically literate, clear about goals and risk, willing to confront problems rather than ignore them. We need to change ingrained habits, accept new challenges, and venture outside our comfort zone. We're no longer just a passenger on the Titanic; we're the captain.
Chapter 3: Objective, Strategy, Tactics – A Road Map for Reading This Book
Strategy without tactics is the slowest route to victory. Tactics without strategy is the noise before defeat.
Sun Tzu
We need to think about and plan for the later decades of our lives. For many, the last ten years of life is not a happy time – they suffer from one or more Four Horsemen; their cognitive and physical abilities are weakening or gone; they're unable to do the activities they once loved. This Marginal Decade is often a period of diminishment and limitation.
What do we want to do in our later decades? Thinking about this both encourages us to focus on our own endgame (which counters hyperbolic discounting or the preference for immediate gratification) and drives home the importance of healthspan.
"Tactics without strategy is the noise before defeat." Before trying to take a shortcut to the tactics, to exercise, eat, and supplement a specific way, we need to formulate a strategy: an overall approach and mental model tailored to our goals. Understanding the strategy and the science behind it will help us avoid uselessly riding the merry-go-round of fad diets, trendy workouts, and miracle supplements.
Longevity means delaying death from all four Horsemen, and the most common risk factor between them is age – as we age, our immune systems weaken, we develop cardiovascular and respiratory issues, etc. We'll take a closer look at some of the mechanisms behind aging, and into the detailed workings of each of the Horsemen diseases.
The deterioration in healthspan happens in three axes:
- Cognitive decline: our processing speed slows down, our memory begins to fade, and our personality even changes.
- Physical body decline: we lose muscle mass, strength, bone density, stamina, stability, and balance. We could fall and end up in a downward spiral from which we never recover. Many activities require a certain level of muscular and aerobic fitness; even now our V̇O2 max could be barely sufficient, let alone years from now.
- Decline in emotional health: how we deal with distress can have a huge bearing on physical health, happiness, and survival.
Avoiding, slowing, or even reversing all of these is the key way to achieve longevity. Conversely, improving cognitive, physical, and emotional health will reduce our risk of dying more than any medications. Improving healthspan will almost always benefit lifespan as well.