Outlive: The Science and Art of Longevity
Peter Attia explains how we can battle the "Four Horsemen" of modernity conspiring to degrade our ability to live a long life free of chronic conditions and disabilities.
“When he opened the fourth seal, I heard the voice of the fourth living creature say, ‘Come!’ And I saw, and behold, a pale horse, and its rider’s name was Death, and Hades followed him; and they were given power over a fourth of the earth, to kill with sword and with famine and with pestilence and by wild beasts of the earth.”
Without the benefits of modern medicine, many of you reading these words would not have survived infancy and childhood. Infectious diseases and accidents often meant certain death for children and adults alike. Medical interventions such as bloodletting, based on humoral theory, were likely to kill patients while poor hygiene in medical settings could doom anyone unfortunate enough to experience a surgical procedure.
In the second half of the nineteenth century, the medical profession made a number of advances centered on the germ theory of disease. This led to the development of antibiotics and better sanitation in medical settings and the result was a major drop in deaths from infectious disease. This development, which Dr. Peter Attia refers to as the shift from Medicine 1.0 to Medicine 2.0, took decades because it meant discarding many long-held beliefs and adopting a completely different mindset.
Accidents and misfortunes that would have been a certain death sentence two hundred years ago are now routinely addressed by Medicine 2.0. In addition, many serious conditions that primarily affect middle-aged and older people are no longer death sentences. Cancer can often be cured or put into long-term remission. The scourge of diabetes can be managed through medication and dialysis. Cardiovascular disease can be treated with effective pharmaceuticals and serious conditions such as aortic valve replacement can now be addressed through minimally invasive surgery.
Medicine 2.0 is excellent when it comes to dealing with infection and trauma and can offer many treatments for chronic diseases once a patient is sick. The trouble is that our medical system is geared toward addressing chronic illness once it presents itself rather than taking aggressive steps to prevent problems from surfacing in the first place. By the time problems are apparent, the medical system can often extend life to some degree but usually can do little to improve a permanently degraded quality of life.
Dr. Peter Attia believes that we need to shift our perspective on chronic diseases. Rather than passively allowing problems to build over years and decades and become entrenched, his conception of 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 of Alzheimer’s disease.” In his new book, Outlive: The Science and Art of Longevity, Attia outlines Medicine 3.0 and how we should reframe our thinking and actions right now to improve our health outcomes decades from now.
At a surface level, a book on health and medicine has little to do with finance and investing, but I think that there are actually many parallels. Both good long term health and a solid financial plan require taking a very long-term mindset right now in order to improve outcomes decades from now. This mindset is relatively uncommon.
Human nature leads most people to have a very short-term mindset. The perceived benefits from eating a few donuts for breakfast, drinking soda, eating a Snicker’s bar, smoking a cigarette, and having several drinks at the bar are obvious right now. The potential cost might involve a diabetes or cancer diagnosis in 2035 or 2040, and the consequences might never arrive for a lucky minority. Many of us delude ourselves into thinking that we will be part of that lucky minority.
The same situation exists when it comes to deciding whether to spend or save money. Although many short-term benefits from excessive spending are illusory, it feels great to spend on immediate consumption in the moment. Putting away money for longer term goals like a down payment on a home or retirement seem very far away. Why not have it both? Consume right now and make up for it by taking on more investment risk or engaging in outright speculation? We know how that movie typically ends.
I suspect that there is a high correlation between people who will read a book like Outlive and make long term behavioral changes and people who are willing to forego current consumption to put away money for the long run. And if you really think about it, those two behaviors make the most sense when they are combined! If you are great at saving money for the long run but die at an early age, you will never benefit from deferred consumption. Even if you make it to your golden years, you could find yourself physically or mentally unable to participate in activities that you enjoy.
The Four Horsemen
The Book of Revelation is the final book in the New Testament. It is an apocalyptic account that can even terrify religious people who believe they will be saved in the end. The Four Horsemen of the Apocalypse are central characters in Revelation, often interpreted to represent conquest, strife, famine, and death. I have always thought of nuclear war while reading The Book Revelation. But the topic of this article isn’t theology. The point is that the Four Horsemen are terrifying characters.
Peter Attia’s Four Horsemen are:
Metabolic dysfunction
Cardiovascular disease
Cancer
Neurodegenerative diseases
For those of us who avoid an early death due to infectious diseases or accidents, one or more of the Four Horsemen are very likely to assault us as we enter middle age unless we take countermeasures. We might not even know that we are being assaulted when the attack begins because the Horsemen are adept at eroding our well-being silently at first. It is only in the fullness of time that symptoms of the assault become obvious, and by that time our health might be impaired beyond repair.
One of the most important take-aways from the book is the central importance of metabolic health. When I researched the dialysis industry last year, I was astounded by the degree to which metabolic disorder is under diagnosed. The CDC estimates that 37.3 million Americans have full blown diabetes. Of this number, 8.5 million had undiagnosed diabetes and were not aware of their condition. In addition, the CDC estimates that 96 million Americans over the age of 18 have “pre-diabetes”, with the vast majority of these people unaware of their condition. These are catastrophically high numbers as a percentage of the population.
The most extreme result of metabolic disorder is when kidneys fail to the point where dialysis or a kidney transplant is necessary to sustain life. By this point, patients are often so weak that their lifestyle has been massively degraded. However, this is the culmination of decades of metabolic disorder. Medicine 2.0 will immediately jump in to keep such patients alive. Medicare actually covers treatment of end-stage renal disease for all Americans, not just those over sixty-five. But the medical system does relatively little to prevent patients from arriving at this destination to begin with.
Metabolic disorders often lead to cardiovascular problems. The Metabolic Horseman effectively gives a major assist to the Cardiovascular Horseman who has already been hard at work impairing our circulatory system, often since our teens or twenties. Atherosclerosis occurs when plaques are deposited in our arteries. These plaques represent assaults on our circulatory system that the body repairs, eventually leading to calcification. Eventually, arteries can degrade to the point where we suffer heart attacks or strokes. Metabolic disorder is an accelerant that promotes such miseries.
The Cardiovascular Horseman is particularly concerning in my case because, like the author, I have a family history of heart problems. Peter Attia is, by all accounts, an exercise fanatic, but this was not enough to prevent calcification of his arteries that was discovered in a coronary calcium test when he was in his mid-thirties.
Over the past decade, Attia has implemented changes that appear to have halted the progression of the calcification. This immediately resonated with me since I recently scored similarly on a coronary calcium test even though I exercise far more than average (although considerably less than Attia) and I have more cardiovascular capacity than the vast majority of individuals in my age cohort. I am almost exactly the same age as Attia and I want to achieve the same results he has reported.
Cancer is one of the scariest words in the English language, especially for those who have witnessed family members succumb to the disease. Actually, cancer is not a single disease but a group of diseases characterized by uncontrolled cellular growth. There has been tremendous progress when it comes to battling the Cancer Horseman, although there are still too many sad cases where metastatic cancer has spread to the point where palliative care is the only realistic option. While the book devotes considerable attention to cancer, those who are particularly interested in the subject should refer to a book such as The Emperor of All Maladies by Siddhartha Mukherjee. Although Mukherjee’s book is several years old, I found it very worthwhile.
Alzheimer’s Disease is probably the most feared variant of the category of ailments knowns as neurodegenerative disease. However, Parkinson’s Disease, Huntington’s Disease, Lou Gehrig’s Disease and many others fall into this category as well.
In the case of Alzheimer’s, there is a strong genetic component involved which is discussed in some detail in the book. This genetic component can be revealed in a widely available test, although some doctors are reluctant to order it because they do not believe that much can be done about it. So why cause patients to be concerned? However, maintaining cardiovascular health has an impact on brain health and there are other steps that can be taken as well. Even discounting the ability to prevent Alzheimer’s, some people will want to know to better plan their retirement years.
Attia mentions that many of his patients fear neurodegenerative diseases like Alzheimer’s the most because the idea of being robbed of one’s mind can seem like a fate worse than death. While far too little can be done to address Alzheimer’s today, that may well change in the decades to come. Keeping the other three Horsemen away could buy time for those genetically susceptible to Alzheimer’s and allow them to benefit from yet-to-be discovered treatments.
Exercise, Nutrition, and Sleep
We are far from powerless when it comes to keeping the Four Horsemen from destroying our health. Even if we eventually succumb to one of the Horsemen in the end, we can delay the onset of the attack for decades, buying additional years or decades of healthy lifespan. Everyone already knows that exercise and nutrition are very important, but sleep is also critical. We need to come up with individualized plans in all three areas to optimize for better health and longevity.
Knowing that something is important is very different than figuring out a personal action plan. One easy way to tell whether you’re dealing with a charlatan is when the prescribed action plan is the same for everyone. The truth is that every individual’s health situation is different and the action plan that each person can sustain will vary widely. Peter Attia avoids making one-size-fits-all recommendations. In order to get a personalized plan of action from Attia, you would have to enroll as a patient which is probably a very expensive proposition. The rest of us can benefit from the guidelines provided in the book.
It is very clear that Attia regards exercise to be the cornerstone of good health which he refers to a the most powerful longevity drug. This makes sense because exercise has multiple benefits from both a physical and mental health perspective and the benefits tend to compound over time. Exercise helps us maintain good metabolic function, keeps our cardiovascular system in shape, and can be extremely beneficial for our mental health as well. Personally, I feel physically and mentally healthy only on days when I go running in the morning.
Perhaps even more importantly, strength training helps us to maintain adequate muscle mass and tone later in life. The truth is that all of us will lose muscle mass as we age, so it is critical to build up a solid baseline. Attia makes the point that if we want to be able to do things like hiking a mountain trail, carrying groceries home from the store, picking up a grandchild, or even climbing the stairs later in life, we need to be able to do much more than those tasks in middle age. If we are struggling to do things at the age of 50 that we want to be doing at the age of 70, chances are that we will be disappointed in two decades without taking corrective action today.
One of the most insightful sections was Attia’s discussion of the importance of stability, something that I completely take for granted today. Falls represent one of the leading causes of death and disability for the elderly. A series of falls caused a hip fracture that resulted in my grandmother losing her ability to live independently and, I suspect, led to a cascade of other serious problems eventually resulting in death. It is hard to imagine being frail, losing balance, falling, and ending up in a nursing home but these are not just things that happen to other people. It can happen to anyone.
Attia avoids prescribing a specific exercise program but he does include links to videos and other resources that can help readers design a cardiovascular and strength training program to suit their needs. This might disappoint some readers, but the reality is that the optimal program depends on too many individual factors to convey in a book.
Nutrition might be an even more contentious topic. I know from my investigations into keto, paleo, vegetarian, and vegan diets how each approach has proponents who seem to view the subject almost religiously. In contrast, Attia provides general commentary and guidelines without being prescriptive. Again, this might disappoint some readers but I found the information quite useful. In particular, Attia’s guidelines on the appropriate level of protein intake were interesting. He recommends at least twice the level of protein compared to government guidelines in order to maintain and improve muscle mass as we get older.
Sleep is a critical factor that most people seem to totally ignore. I have had serious problems with sleep over the years and intuitively know that this has affected my health. However, the degree to which lack of sleep causes harm was not something I was fully aware of before reading this book. If there’s one take-away from the sleep chapter that I plan to act on soon, it is the importance of darkness. I need to upgrade from mini blinds to room darkening curtains.
A Long Life of Misery?
What is the point of living a long life, even in good physical health, if you are going to be miserable during those extra years?
This is an important question that Peter Attia delves into in much detail using his own challenges with emotional health as a case study. I cannot imagine how difficult writing the final chapter of the book must have been, nor would I have ever suspected that someone like Attia would have faced such issues in his past.
Mental health is either totally neglected or treated in a cursory manner by Medicine 2.0. I cannot recall any doctor ever asking about my mental or emotional health until I switched to a Kaiser Permanente plan in 2022. Kaiser has a medical questionnaire that asks about such topics, but still in a relatively cursory manner. Given the importance of mental health, it should probably be more central in annual physical exams.
If exercise and nutrition must be tailored individually, that is even more true when it comes to achieving good mental health. Each individual has a different background in terms of religion, philosophy, and general outlook on life. In general, I would suggest that studying philosophy is the cornerstone of good mental health. I have found stoicism particularly useful, especially the guidance provided by Marcus Aurelius.
I will close by returning to my initial comments on the relationship between money and health. Most people want to live as long as possible while enjoying good health into old age and having sufficient financial resources to live as they please.
Although the book’s message is a hopeful one, it is also sobering. The reality is that advancing age involves inevitable physical decline eventually. We can build up our baseline level of strength and fitness in middle age to delay the onset of frailness as far into the future as possible, but it is all but a guarantee that certain physical pursuits are going to be easier to accomplish at a younger age.
What I take away from this reality is that it makes sense to front load particularly demanding physical activities earlier in life, even if that means saving less money or doing the activity in a less luxurious way. The good news is that foregoing luxuries often enhances experiences when we are younger and having access to money can make travel more endurable as we get older. Like exercise and nutrition, there is no one-size-fits-all prescription for saving, investing, and consuming.
Additional Resources
In the following video, Peter Attia discusses the process of writing the book:
I also recommend this deep dive into cardiovascular health:
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Great review! I would also add the Tim Ferris interview of Ed Thorp also has useful tips about how to stay in shape and aid in longevity.
Very informative as usual. Much appreciated.